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Nurses’ care preferences and the quality of nursing care : comparison of the characteristics and the… Garry, Helen Bernice 1982

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NURSES' CARE PREFERENCES AND THE QUALITY OF NURSING CARE COMPARISON OF THE CHARACTERISTICS AND THE NURSING CARE RECEIVED FOR SELECTED HIGH AND LOW PREFERENCE HOSPITALIZED PATIENTS * by HELEN BERNICE GARRY B.Sc.N., The University of B r i t i s h Columbia, 1970 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE DEPARTMENT OF HEALTH CARE AND EPIDEMIOLOGY IN THE PROGRAMME OF HEALTH SERVICES PLANNING We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l 1982 © Helen Bernice Garry, 1982 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department U J - jr-~> «= ^ — The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date DE-6 (3/81) ABSTRACT In a f i e l d study t h i r t y - t h r e e Registered Nurses were requested to s e l e c t , from the patients currently on t h e i r nursing u n i t s , those patients who were perceived as most or least preferred patients by the majority of the unit nurses. The patient sample siz e included f o r t y least preferred and f o r t y most preferred patients. A f t e r the preference s e l e c t i o n each nurse responded to questions which i d e n t i f i e d t h e i r perceptions of the socio-economic, and i l l n e s s status of the selected patients. A patient behaviour r a t i n g scale was scored by each nurse f or each patient. The scale included t h i r t y - s i x adjective descriptors, d i s t r i b u t e d equally between conforming and nonconforming patient behaviours. 'Problem' patients were well described by the nonconforming or deviant behavioural adjectives while the most preferred patients were described as being very conforming or compliant p a t i e n t s — c o o p e r a t i v e , easy to please, considerate and appreciative. The data also revealed that patients with a lengthy h o s p i t a l i z a t i o n , a chronic i l l n e s s or a poor prognosis were least preferred by the nurses. The e f f e c t s of nurse care preferences were analyzed i n r e l a t i o n to the influence on the q u a l i t y of nursing care received by each of the patient preference groups. The findings revealed that the q u a l i t y of nursing care does d i f f e r f o r the high and low patient preference groups but the only s i g n i f i c a n t q u a l i t y score difference appeared i n the psychosocial needs category. Three of the study's n u l l hypotheses were accepted. Nurse care preferences were not systematically r e l a t e d to: 1. the demographic c h a r a c t e r i s t i c s of the patients; 2. the patients' socio-economic status; or 3. the patient needs c l a s s i f i c a t i o n (workload). Three hypotheses were rejected. Nurse care preferences were s i g n i f i c a n t -l y r e l a t e d to: 1. the i l l n e s s status of the patients; 2. the behavioural descriptions of the patients; and 3. the q u a l i t y of nursing care. The meaningfulness of these findings and the implications f o r further research are considered. i v TABLE OF CONTENTS PAGE ABSTRACT i i LIST OF TABLES- • v i i i LIST OF FIGURES x i ACKNOWLEDGEMENTS x i i CHAPTER PAGE I " BACKGROUND OF THE PROBLEM 1 Introduction 1 Statement of the Problem 3 II REVIEW OF THE LITERATURE 4 Role Conceptions 4 Sick Role 4 Professional, Bureaucratic Roles 6 Role Perceptions 10 Ho s p i t a l i z e d Patients 10 Role Preferences/Nurse Attitudes 11 Role Performance 13 Quality of Nursing Care 13 Sampling Concepts 14 III CONCEPTUAL FRAMEWORK 17 IV PURPOSES OF THE STUDY 20 Hypotheses 20 CHAPTER PAGE IV PURPOSES OF THE STUDY (Continued) D e f i n i t i o n s 21 Assumptions 22 Limitations 23 V METHODOLOGY 24 P i l o t Study 24 Data C o l l e c t i o n 27 Selec t i o n of Nursing Units 27 Sel e c t i o n of Nurse Sample 27 Sel e c t i o n of Patient Sample 29 Instruments 29 Adjective Descriptor Rating Scale 29 Patient Needs C l a s s i f i c a t i o n 33 Quality of Nursing Care Scale 33 Objective and Subobjective Structure 34 Data Coding and Analysis Procedures 35 Information About the RN Pa r t i c i p a n t s 35 Information About the Patient Sample 36 Analysis of the Adjective Descriptors Rating Scale 37 Analysis of the Quality of Nursing Care Scale 38 Summary of the Data Analysis Procedures 39 VI FINDINGS 41 General Responses of the Par t i c i p a n t s Toward the Study 41 Ch a r a c t e r i s t i c s of the Par t i c i p a n t s 43 Description of the Nurses 43 v i CHAPTER VI FINDINGS (Continued) Description of the Patients Demographic Data Socio-Economic Data I l l n e s s Data Patient "Care Needs" C l a s s i f i c a t i o n Adjective Descriptors Rating Scale Discriminant Function Analysis of Patient Group Membership Quality of Nursing Care Scores VII SUMMARY, CONCLUSIONS AND IMPLICATIONS Summary of Purposes and Procedures Summary of Findings C h a r a c t e r i s t i c s of the RN Sample C h a r a c t e r i s t i c s of the Patient Sample Hypothesis I Hypothesis II Hypothesis III Hypothesis IV Responses to the Adjective Descriptor Rating Scale Hypothesis V Quality of Nursing Care Scores Hypothesis VI Conclusions 1. The extent and meaningfulness of RN Care Preferences has been underestimated v i i CHAPTER PAGE VII SUMMARY, CONCLUSIONS AND IMPLICATIONS (Continued) 2. Nurses' s e l e c t i o n of the least preferred patient i s most strongly r e l a t e d to at t r i b u t e d non-conforming or deviant patient behaviours 82 3. The i n s t i t u t i o n a l i z e d expectations of patient sick r o l e behaviours have been " i n t e r n a l i z e d " by nurses 83 4. The i l l n e s s status of the patient does influence the nurses' s e l e c t i o n of low and high preference patients . 85 5. The q u a l i t y of nursing care received by the least preferred patients i s lower than the care received by the most preferred patients 86 Implications 87 BIBLIOGRAPHY 89 APPENDICES A AMERICAN NURSES ASSOCIATION CODE OF ETHICS:: 95 B CANADIAN NURSES ASSOCIATION CODE OF ETHICS 97 C DEPARTMENT OF MEDICAL NURSING PATIENT CARE STUDY 100 Nurse Consent Form 100 Patient Consent Form 101 Information f o r Physicians 102 D PATIENT CLASSIFICATION FORM 103 E OBJECTIVE AND SUBOBJECTIVE STRUCTURE 104 F MEDICUS NURSING QUALITY MONITORING INSTRUMENT WORKSHEET 2001 106 G SELECTED STATISTICAL PACKAGE FOR THE SOCIAL SCIENCES (SPSS) PROGRAM OPTIONS FOR THE DISCRIMINANT FUNCTION ANALYSIS 116 v i i i LIST OF TABLES TABLE PAGE I DISTRIBUTION OF RN CHARACTERISTICS BY UNIT, NURSING EDUCATIONAL PROGRAM, AGE, AND LENGTH OF EXPERIENCE IN NURSING 44 II PATIENT AGE DIFFERENCES BETWEEN THE TWO PRE-FERENCE GROUPS: T-TEST 45 III FREQUENCY DISTRIBUTION FOR PATIENT PREFERENCE GROUP AND RN PERCEPTION OF PATIENT EDUCATION 46 IV FREQUENCY DISTRIBUTION FOR PATIENT PREFERENCE GROUP AND RN PERCEPTION OF PATIENT OCCUPATION 47 V FREQUENCY DISTRIBUTION FOR PATIENT PREFERENCE GROUP AND RN PERCEPTION OF PATIENT CLASS STATUS 47 VI FREQUENCY DISTRIBUTION FOR PATIENT PREFERENCE GROUP AND PATIENT RELIGIOUS CLASSIFICATION 48 VII FREQUENCY DISTRIBUTION FOR PATIENT PREFERENCE GROUP AND RN PERCEPTIONS OF PATIENT ILLNESS STATUS 49 VIII PATIENT LENGTH OF HOSPITALIZATION AND THE PRE-FERENCE GROUP MEMBERSHIP 50 IX FREQUENCY DISTRIBUTION OF THE CLASSIFICATION OF PATIENT CARE NEED AND PATIENT PREFERENCE GROUP MEMBERSHIP 51 X PATIENT NEEDS CLASSIFICATION AND PATIENT PRE-FERENCE GROUP MEMBERSHIP: T-TEST 51 i x TABLE PAGE XI FREQUENCY DISTRIBUTION FOR PATIENT PREFERENCE GROUP AND RN PERCEPTIONS OF PATIENTS' EMO-TIONAL NEEDS STATUS 52 XII COMPARISON OF HEAD NURSE AND RN PERCEPTIONS OF PATIENTS* EMOTIONAL NEEDS STATUS 53 XIII RANK ORDER DISTRIBUTION OF HIGHEST MEAN SCORES BASED ON THE ADJECTIVE DESCRIPTORS RATING SCALE FOR BOTH PATIENT PREFERENCE GROUPS 55 XIV RANK ORDER DISTRIBUTION OF LOWEST MEAN SCORES BASED ON THE ADJECTIVE DESCRIPTORS RATING SCALE FOR BOTH PATIENT PREFERENCE GROUPS 56 XV MEAN SCORE DIFFERENCES FOR THE ADJECTIVE DESCRIP-TORS BETWEEN THE HIGH AND LOW PATIENT PREFERENCE GROUPS 58 XVI SUMMARY FOR THE INCLUSION OF ADJECTIVE DESCRIPTORS IN THE DISCRIMINANT FUNCTION ANALYSIS 62 XVII ADJECTIVE DESCRIPTOR RATINGS AND PATIENT GROUP MEMBERSHIP - DISCRIMINANT FUNCTION ANALYSIS 63 XVIII REGRESSION COEFFICIENTS BASED ON THE NURSES' SELECTED PATIENT GROUP MEMBERSHIP AND THE NUR-SES' PATIENT DESCRIPTOR RATINGS 66 XIX DISTRIBUTION OF THE QUALITY OF NURSING CARE SCORES OVER THE FOUR MAJOR OBJECTIVES FOR EACH NURSING UNIT AND PATIENT PREFERENCE GROUPS 67 X TABLE PAGE XX MEAN SCORES AND STANDARD DEVIATIONS OF THE QUALITY OF NURSING CARE SCORES OVER THE FOUR OBJECTIVES AND BETWEEN BOTH PATIENT PREFERENCE GROUPS 69 XXI TWO-WAY ANALYSIS OF VARIANCE FOR PATIENT PRE-FERENCE GROUP AND THE QUALITY OF NURSING CARE 71 XXII ONE-WAY ANALYSIS OF VARIANCE FOR PATIENT PRE-FERENCE GROUP AND THE QUALITY OF NURSING CARE SCORES AMONG THE FOUR OBJECTIVES 72 XXIII DISTRIBUTION OF THE MEDICUS QUALITY OF NURSING CARE CRITERIA FOR THE FOUR OBJECTIVES AND THE INFORMATION SOURCE 74 v x i LIST OF FIGURES FIGURE PAGE 1 MODEL OF STUDY VARIABLES: AFFECTIVE AND BEHAVIOURAL RELATIONSHIPS 18 2 ADJECTIVE DESCRIPTORS RATING SCALE 31 3 DEMOGRAPHIC, SOCIO-ECONOMIC AND ILLNESS-RELATED DATA SHEET 32 4 GRAPHIC REPRESENTATIVE OF THE MEAN DESCRIPTOR RATINGS FOR BOTH PATIENT PREFERENCE GROUPS 59 5 GRAPHIC REPRESENTATION OF THE DESCRIPTOR SCORES FOR THE LARGEST GROUP MEAN DIFFERENCES BETWEEN THE TWO PATIENT PREFERENCE GROUPS 61 6 DISCRIMINANT FUNCTION ANALYSIS FOR PATIENT GROUP MEMBERSHIP: CLASSIFICATION OF RN PREFERENCE RATINGS AND THE PATIENT BEHAVIOURAL DESCRIPTOR RATINGS 64 7 DISTRIBUTION OF THE QUALITY OF NURSING CARE SCORES OVER THE FOUR MAJOR QUALITY OBJECTIVES FOR EACH NURSING UNIT AND PATIENT PREFERENCE GROUP 68 8 QUALITY OF NURSING CARE "OBJECTIVE" SCORES FOR THE HIGH AND LOW PREFERENCE PATIENT GROUPS 70 x i i ACKNOWLEDGEMENTS I am most appreciative of the support I received from the persons i n the Canadian Research Programs Directorate. Without t h e i r f i n a n c i a l assistance t h i s study would not have been conducted. The i n t e r e s t and support of Parke Davidson, Past Director of C l i n i c a l Psychology at the University of B r i t i s h Columbia was most encouraging and stimulating. My mother, Annie Garry, i s fondly remembered for the time she spent i n the d i l i g e n t coding of the data. 1 CHAPTER I BACKGROUND OF THE PROBLEM Introduction The determination of v a l i d and r e l i a b l e i n d i c a t o r s of the q u a l i t y of nursing case was given the highest p r i o r i t y ranking i n a large U.S. nursing survey (Lindeman, 1975). The burgeoning of q u a l i t y assurance programs i n nursing a t t e s t s to the increasing commitment of nurses and health case agencies to the issue of the q u a l i t y of care. The i d e n t i f i c a t i o n and c l a r i f i c a t i o n of nurses values i s a core concept in the development and evaluation of a l l q u a l i t y assurance programs i n nursing (Zimmer, 1973; Registered Nurses Association of B.C., 1977). Values, l i k e a l l b e l i e f s or att i t u d e s , have cognitive, a f f e c t i v e and behavioural components. According to Rokeach a value: (1) " i s a cognition about the desirable. To say that a person has a value i s to say that cogni-t i v e l y he knows the correct way to behave or the correct end-state to s t r i v e f o r . [A value i s also] (2) a f f e c t i v e i n the sense that he can f e e l emotional about i t , be a f f e c t i v e l y f o r or against i t , approve of those who exhibit p o s i t i v e instances and disapprove of those who exhibit negative instances of i t ; and (3) a value has a behavioural component in the sense that i t i s an intervening variable that leads to action when activated" (Rokeach, 1973). The major sources of nursing values are s o c i e t a l , s c i e n t i f i c and pro-f e s s i o n a l . S o c i e t a l values are r e f l e c t e d i n the answers given to questions about health, about nursing p r a c t i c e , and about the use of economic resources. S o c i e t a l values define which end r e s u l t s are desirable and which are not and 2 what i s the l e v e l of health care that a society i s w i l l i n g to accept and pay f o r . Steele and Harmon take the view that as society and i t s values change, the c h a r a c t e r i s t i c s of q u a l i t y must also change. Increases i n s c i e n t i f i c or technological knowledge also require a re-examination of e x i s t i n g values, and some l i k e l y changes i n an i n d i v i d u a l ' s value hierarchy (Steel and Harmon, 1979). Professional values are most often embodied i n a Code of E t h i c s . In the' introduction to the American Nurses Association, A Code f o r Nurses, i t states that "The requirements of the Code may often exceed but are never less than those of the law. . . . (The professional association) may reprimand, censure, suspend or expel . . . members from the Association for v i o l a t i o n s of the Code'.' (American Nurses Association, 1976). The Code i s presented i n Appendix A. The recent Canadian Nurses Association Code does not r e f e r to any p o t e n t i a l negative sanctions i f Code v i o l a t i o n s do occur. As one of the general p r i n -c i p l e s the Code states that "the human person, regardless of race, creed, color, s o c i a l c l a s s or health status, i s of i n c a l c u l a b l e worth and commands reverence and respect".(Canadian Nurses Association, 1980). The remaining 'General P r i n c i p l e s ' and 'Statements of E t h i c a l R e s p o n s i b i l i t y ' are included i n Appendix B. Although the Codes acknowledge that the personal a t t r i b u t e s of patients as well as t h e i r values, b e l i e f s and attitudes d i f f e r and influence nursing p r a c t i c e they should do so only i n s o f a r as they represent factors that the nurse must understand, consider and respect i n planning care to meet i n d i v i d u a l patient needs. Preferences of nurses, t h e i r l i k e s and d i s l i k e s are not mentioned i n the Codes. This omission does not eliminate the f a c t that the nurse's feelings i n her contacts with patients are important factors which need to be recognized i n order to e f f e c t r e a l "caring" f o r : nurse-patient; nurse-nurse; and nurse-3 others. Morimoto believed that the 1950's o r i e n t a t i o n towards i n d i v i d u a l . differences and the s t r e s s i n g rather than minimization of the importance of nurses' f e e l i n g s was a p o s i t i v e development (Morimoto, 1955). Neither the nursing Codes of Ethics nor the values i d e n t i f i c a t i o n associated with q u a l i t y assurance programs have s i g n i f i c a n t l y a l t e r e d the perceptions and attitudes of nurses towards those patients who are commonly r e f e r r e d to as "problem pa t i e n t s . " As a group these problem or least preferred patients may exhibit simi-l a r behaviours, needs or c h a r a c t e r i s t i c s which evoke a negative emotional response from the nurse care givers. Regardless of the nurses' cognitive, professional ideals or values her performance or behaviours with respect to these problem patients may adversely a f f e c t the q u a l i t y of nursing care. Statement of the Problem This research was undertaken i n order to i d e n t i f y : (1) which patients are most/least preferred by nurses; (2) why; and (3) what differences do nurses' care preference make to the q u a l i t y of nursing care received by either patient group. 4 CHAPTER II REVIEW OF THE LITERATURE The nature of nurses' attitudes towards t h e i r h o s p i t a l i z e d patients de- .„ r i v e from a complex i n t e r a c t i o n among the needs, values, goals and expecta-tions of the i n s t i t u t i o n , the care providers and the c l i e n t s . There i s a plethora of r e l a t e d l i t e r a t u r e a v a i l a b l e i n many academic f i e l d s . Role Conceptions Sick Role The c l a s s i c t h e o r e t i c a l elaboration of the sick r o l e was developed by Parsons i n 1951. Parsons contended that i l l n e s s was a form of s o c i a l deviance, and c o n d i t i o n a l l y l e g i t i m i z e d by the physician as the agent of s o c i a l c o n t r o l . The r o l e of the sick person was described i n terms of two major r i g h t s and two major duties which constituted the " i n s t i t u t i o n a l i z e d r o l e expectations." These four c l o s e l y i n t e r - r e l a t e d dimensions are: (1) The occupant of the s i c k r o l e i s exempt from r e s p o n s i b i l i t y f o r the incapacity and i s also (2) exempt from normal s o c i a l r o l e r e s p o n s i b i l i t i e s . (3) The sick person i s expected to recognize that i l l n e s s i s inherently undesirable and to f e e l obliged to t r y to get well and (4) to seek and cooperate with t e c h n i c a l l y competent help. Dependency, p a s s i v i t y and psychological regression of the sick person and h i s family were what Parsons postulated as t h e i r i l l n e s s response due to t h e i r emotional involvement, lack of o b j e c t i v i t y and t h e i r technical incompetence. Severe anxiety or s t r a i n during i l l n e s s may r e s u l t i n a denial of i l l n e s s or the sick person may give i n to a f e e l i n g of t o t a l 5 helplessness and demand excessive care and attention. Parsons a t t r i b u t e s differences i n i n d i v i d u a l reactions to i l l n e s s and differences between r o l e expectations and r o l e behaviour to psychological f a c t o r s . In other words the s o c i a l aspects of sick r o l e or sick r o l e deviance are e i t h e r neglected or denied. I l l n e s s , as deviance may also be motivated by the patient's norms, expectations, goals and/or means. This "mental i l l n e s s " perspective i s pre-sented by Parsons i n his 1975 writings (Parsons, 1975). Parsons acknowledges some s i m i l a r i t i e s between t h i s l a t t e r sick r o l e formulation and Merton's formulation of the retreatism adaptation mode (Merton, 1968). Merton considered that a conforming i n d i v i d u a l i s conforming because he accepts both the s o c i e t a l (or professional) goals and the i n s t i t u t i o n a l i z e d means of achieving those goals. A l l other adaptation modes are relegated to the "deviant status" and Merton categorizes these as retreatism, r i t u a l i s m , r e b e l l i o n or innovation. Parsons--in a most rare non-Parsonian moment--admitted that "by no means a l l types of 'conformity' with ( s o c i e t a l ) performance standards can be c a l l e d 'health' nor a l l types or modes of deviation from such conformity ' i l l n e s s ' (Parsons, 1975). A few doubters of the Parsonian psychological o r i e n t a t i o n towards any var i a t i o n s i n t h e o r e t i c a l l y formulated sick r o l e behavioural expectations have undertaken empirical studies to v a l i d a t e the concept and to question some of i t s key assumptions. Mechanic and Volkart (1960) and Kasl and Cobb (1964) found that i l l n e s s behaviour d i f f e r e d with medical diagnosis. Zola (1964) investigated i l l n e s s behaviour and the working c l a s s , and Zborowski, i n 1952, and Seg a l l , i n 1976, explored s o c i o - c u l t u r a l v a r i a t i o n s i n perceptions of s i c k r o l e behaviour and expectations. In a summary statement of a study, Kassebaum and Baumann conclude that: "Demographic and socio-economic difference 6 by themselves are not s u f f i c i e n t to account f o r differences i n sick role expectations." The most comprehensive study of sick r o l e expectations was conducted by Gordon (1966). His eight hypotheses were concerned with the i d e n t i f i c a t i o n of the influence of socio-economic status, such as income and education on a person's perceptions of a number of i l l n e s s dimensions; f o r example, medical prognosis, functional d i s a b i l i t y , dependency needs and r o l e r e l a t i o n s . A l -though four of the eight alternate hypotheses were supported, the study stops short i n discussing or summarizing the implications of these findings. I t may be that Gordon's research as well as most of those r e f e r r e d to e a r l i e r were unable to adequately test t h e i r hypotheses or explain t h e i r findings due to methodological problems which so often occur i n the survey approach to research. Professional, Bureaucratic Roles Parsons considered medicine as the p r o t o t y p i c a l profession. Foremost i n the physician's value-orientation he included: (1) a c o l l e c t i v e vs_ p r i v a t e i n t e r e s t ; (2) a u n i v e r s a l i s t i c and a f f e c t i v e l y neutral standard; and (3) a functional s p e c i f i c i t y vs diffuseness. A l l - i n - a l l these values indicate that professionals have to attempt to balance the technical and moral components within t h e i r s o c i a l r o l e . Or as Parsons further states that the sick r o l e and medical p r a c t i c e : i s inherently u n i v e r s a l i s t i c i n that generalized objective  c r i t e r i a determine whether one i s or i s not s i c k , how s i c k , and with what kind of sickness, . . . It i s also function- a l l y s p e c i f i c , confined to the sphere of health, and par-t i c u l a r 'complaints' and d i s a b i l i t i e s within that sphere. It i s furthermore a f f e c t i v e l y neutral i n o r i e n t a t i o n i n that the expected behaviour 'trying to get w e l l ' i s focused on an objective problem, not on the c a t h e t i c (reward) s i g n i f i c a n c e of persons, . . . The o r i e n t a t i o n 7 of the sick r o l e v i s - a - v i s the physician i s also defined as c o l l e c t i v e l y - o r i e n t e d . It i s true that the patient has a very obvious s e l f - i n t e r e s t i n getting well i n most cases . . . But once he has c a l l e d i n a physician . . . he has assumed the o b l i g a t i o n to cooperate with  that physician. The therapist (physician) as an agent of s o c i a l control i s expected to respond to the sick person with support, permissiveness, and r e s t r i c t e d r e c i p r o c i t y — s e l e c t e d rewards and reinforcements. Parsons sets up a theore-t i c a l sex role-pattern contradiction when he claims that childhood s o c i a l i -zation and the, physician's s o c i a l control of the sick consist of s i m i l a r pro-cesses of adjustment to the s t r a i n s of growing up or to i l l n e s s . This appears r as an expressive/instrumental r o l e dilemma. Another extremely important aspect of the control r e l a t i o n s h i p , notably the control of communication i s also mentioned by Parsons but he believed that the i l l or deviant person's psycho-l o g i c a l and a t t i t u d i n a l reactions were more c r u c i a l factors i n e f f e c t i n g the i l l person's behaviour responses. Persons who do not wish to conform to t h i s passive, dependent patient r o l e or r e j e c t t h i s o b j e c t i f i c a t i o n - o f - s e l f have, according to Parsons, only two options: (1) to request a r e f e r r a l to a medical consultant ( s p e c i a l i s t ) ; or (2) to inform the physician that h i s services are no longer desired (required). Marston (1970) and Vincent (1971) present an in-depth review and analysis of patient non-compliance with medical regimens. In t e r e s t i n g l y , only four of the eighty-six compliance studies which were reviewed by Marston were con-ducted i n h o s p i t a l s e t t i n g s : Roth and Berger (1960); Davis (1966); Davis (1967); and Seeman and Evans (1962). Vincent's focus was the assessment of Parsons' sick r o l e c r i t e r i o n of patient cooperation with " t e c h n i c a l l y competent help". None of the reported findings present an unambiguous pi c t u r e of the determinants of sick r o l e de-r 8 viance or non-compliance. Many d i f f e r e n t independent variables have been i n -cluded i n the reported studies. These include demographic medical diagnoses, s o c i o - c u l t u r a l and a t t i t u d i n a l v a r i a b l e s . The professional medical model also i n f e r s that the physician may withdraw his services d i r e c t l y (or covertly) whenever noncompliance indicates that treatment or medication orders are not * accepted by the patient. In contrast to the Parsonian deviance model of i l l n e s s and the physician's .role as an agent of s o c i a l c o n t r o l , Gallagher (1976) proposes a s o c i a l adapta-t i o n model of i l l n e s s which he believes i s most f i t t e d to persons with long term i l l n e s s or i n c a p a c i t i e s . This approach s i g n i f i c a n t l y a l t e r s the expected r o l e behaviours of the physician and the patient. The question of what constitutes good adaptation depends upon value-patterns at the broadest s o c i e t a l l e v e l . According to Gallagher the patient i s a p a r t i c i p a n t i n the choice of the health care goals and the medical technical means. It i s acknowledged that the patient's decision w i l l be i n accordance with some personal values hierarchy. Adaptation has an environ-mental and s i t u a t i o n a l reference so that no two patients with the same diagnosis would n e c e s s a r i l y be treated i n the same way. Gallagher's conception of the patient " r o l e " i s congruent with the Canadian Nurses Association's p h i l o s o p h i c a l statement about nursing: Nurses value a h o l i s t i c view of man and regard him as a biopsychosocial being who has the capacity to set goals and make decisions and who has the r i g h t and r e s p o n s i b i l i t y to make informed choices congruent with h i s own b e l i e f s and values. (Canadian Nurses Association, 1980). Nursing has tended to follow the medical model i n developing codes to guide professional behaviours. Problems of a p p l i c a t i o n a r i s e because the Code i s a l i s t of general rules which on the surface seem e i t h e r " t r i t e " or 9 so fundamental that p r a c t i c e discrepancies pass unnoticed (Steele and Harmon, 1979). In a p r a c t i c a l sense that does patient " d i g n i t y , " "worth," and "reverence" mean to the professional nurse? In Corwin's study of the r o l e conceptions of nurses, He.questions whether nurses value the pro f e s s i o n a l , bureaucratic or service o r i e n t a t i o n i n nursing — i n theory and in pr a c t i c e (Corwin, 1960: 101). He believed that both the p r o f e s s i o n a l i z a t i o n and bureaucratization trends have been at the expense of the service r o l e o r i e n t a t i o n . Bureaucratization, required f o r the mass administration of patients, has led to impersonality, r i g i d routine, task o r i e n t a t i o n and increasing administrative duties, a l l of which have at the expense of personal intimate contacts with patients according to t h e i r need. Professionalism has required increasing s p e c i a l i z a t i o n , increasing technical p r o f i c i e n c y and increasing medical knowledge, attention to which diverted the attention of nurses from the t r a d i t i o n a l service o r i e n t a t i o n toward achievement of prestige within the medical community. Hospital administration and physicians both have "authority" to d i r e c t the a c t i v i t i e s of h o s p i t a l employed nurses. As Smith states, "Two Lines of Authority are One too Many" (Smith, 1955). Nurses have long been attempting to a r r i v e at t h e i r own d e f i n i t i o n of t h e i r p r o f e s s i o n al r o l e . A l t e r n a t i v e s u s u a l l y involve choices between two or three service f o c i . The most popular alternate r o l e o r i e n t a t i o n include: (1) Care vs Cure vs Coordination (National League of Nursing, 1967); (2) Expressive vs Instrumental (Leonard, 1966); (3) Episodic vs D i s t r i b u t i v e (Lysaught, 1970); and the (4) Independent-Dependent-Interdependent nursing r o l e (Canadian Nurses Association, 1980). Another i d e o l o g i c a l t r i a d worth considering i n the organization of hospi-t a l work i s suggested by Coser (1958). Ward patterns are categorized as cus-10 t o d i a l , medical-intervention and therapeutic i n t e r a c t i o n modes. I t i s usual that a general medical ward w i l l have some patients t h a t ^ f i t into each cate-gory and most nurses p r e f e r to work with patients who require active medical intervention and assume that the patient can be "cured" and discharged. The custodial pattern, also c a l l e d the domestic service pattern, p r i m a r i l y i n -volves patient feeding, c l o t h i n g and bathing, and i s premised on the b e l i e f that nothing more can (or should) be done for these p a t i e n t s . The therapeutic-i n t e r a c t i o n model encompasses "comprehensive care" i n which the patient and family are expected to a c t i v e l y p a r t i c i p a t e i n decision-making, goal s e t t i n g and the evaluation of care. The bureaucratic i n s t i t u t i o n also claims a u n i v e r s a l i s t i c value o r i e n t a -t i o n as well as a f f e c t i v e n e u t r a l i t y , functional s p e c i f i c i t y and c o l l e c t i v e i n t e r e s t s . ; Role Perceptions H o s p i t a l i z e d Patients When a patient enters a h o s p i t a l , he or she i s an outsider i n the health professional's place of work. As "guests" they are expected to be appreciative of the services offered by t h e i r "host and hostess". Hospital routines and rules are applied f o r the smooth and e f f i c i e n t running of the i n s t i t u t i o n . Patients whose behaviours disrupt these routine a c t i v i t i e s or those who do not express a concern f o r other patients' needs and the "busyness" of the doctors and nurses are most often l a b e l l e d as problem patients (Lorber, 1975). Tagliacozzo and Mauksch (1972) reported that the patients i n t h e i r study often 11 held conceptions about the nature of some doctors and nurses and the conditions under which they work. Thus, the b e l i e f that some nurses do not l i k e 'demanding patients' leads to the concern of many patients that asking f o r too much may r e s u l t i n a slow response to a c a l l or i n reduced attention to t h e i r needs. The b e l i e f that some nurses and some physicians may be prone to oversights because they are i n e v i t a b l y overworked and rushed may further contribute to patient i n s e c u r i t y . s Patients often v o l u n t a r i l y apologize f o r t h e i r c a l l to the nurse since she "seems so busy". These very conforming patients are not usually viewed by nurses as t h e i r most preferred patients. The patient who i s too s t o i c a l or a too passive patient can also disrupt the treatment or management routine (Lorber, 1975) . ,.u . . From the nurses' d e s c r i p t i o n o f p a t i e n t s , Duff and Hollingshead (1968) concluded that patients were divided into two categories--"problem" and "no problem" . . . Problem patients obstructed work and no problem patients f a c i l i t a t e d work. Although the deviance framework has been considered as a viable construct by many medical s o c i o l o g i s t s , (Twaddle,•1973; Freidson, 1970; , Lorber, 1976; and Scheff, 1965), some have expressed t h e i r concern about the consequences of the l a b e l l i n g and stereotyping of patients who do not f i t into Parsons' t h e o r e t i c a l sick r o l e behaviour model. Role Preferences/Nurse Attitudes The adage that states that attitudes are caught and not taught i s ex-panded by Freidson (1970), . . . studies provide evidence that quite c r i t i c a l elements of professional behaviour--the l e v e l of technical performance, the approach to the c l i e n t , 12 "cynicism" and e t h i c a l i t y — d o not vary so much with the i n d i v i d u a l ' s formal professional t r a i n i n g as :". with the s o c i a l s e t t i n g i n which he works a f t e r h i s education. [These studies] r e i n f o r c e my be-l i e f that ... a s i g n i f i c a n t amount of behaviour i s s i t u a t i o n a l i n c h a r a c t e r — t h a t people are constant-l y responding to the organized pressures of the s i t u a t i o n s they are i n in any p a r t i c u l a r time, that what they are i s not completely but more t h e i r present than t h e i r past, and that what they do i s more an outcome of the pressures of the s i t u a t i o n they are i n than of what they have e a r l i e r " i n t e r n a l i z e d . " Much of the early nursing l i t e r a t u r e regarding problem patients u t i l i z e d a case study approach: Ujhely (1963), MacGregor (1967). One early exception was Morimoto's 1955 study about f a v o r i t i s m and nurse patient i n t e r a c t i o n . She found that nurses i n i t i a t e d i n t e r a c t i o n with preferred patients more often than with the non-preferred patients and that the non-preferred patients were approached i n an impersonal manner. The preferred patient was treated l i k e a biopsychosocial person; the non-preferred l i k e a physical patient. Retrospective studies of nurses' perceptions of or a t t i t u d e s towards pa-t i e n t s have been conducted by a number of researchers. Blaylock (1972) and Reickelman (1972) found that nurses react p o s i t i v e l y to patients who were co-operative, f r i e n d l y and obedient and react negatively to patients who were s e l f i s h , demanding and overly dependent. Similar a t t r i b u t i o n s have been e l i c i t e d by other researchers using nurse interviews and observations of care (Lorber, 1975; Smith and Apfeldorf, 1975; Gladstone, 1980; Stockwell, 1972; Tagliacozzo and Mauksch, 1958; and Duff and Hollingshead, 1968). The only nursing study that was experimental in design was Larson's 1977 study. Nurses' perceptions regarding patients with a lower socio-economic status and a less s o c i a l l y acceptable medical diagnosis were described as". being dependent, passive, u n i n t e l l i g e n t , noncomprehending, unmotivated, lazy, f o r g e t f u l , inaccurate, careless, uninformed, unsuccessful, and u n r e l i a b l e . 13 The nurses' mean score ratings or patient c h a r a c t e r i s t i c s were generally more p o s i t i v e than negative, therefore, some response bias or a s o c i a l d e s i r a b i l i t y e f f e c t may have been operating. S o c i a l d e s i r a b i l i t y ' i s also a value and c o g n i t i v e l y a nurse knows the expected a t t i t u d e or the preferred way to perceive her patients. Role Performance Quality of Nursing Care Freidson has written extensively about most aspects of professional com-petence. He states that the professional believes that the "profession i s the sole source of competence to recognize deviant performance, and i t i s also e t h i c a l , enough to control deviant performance and to regulate i t s e l f i n general". Extensive t r a i n i n g , a service or " c o l l e c t i v e " value-orientation and adherence to a code of ethics are general p u b l i c expectations of professionals. The c r i t i c a l element i s to d i s t i n g u i s h expectations from performance. The evaluation of the q u a l i t y of nursing care i s an emerging professional s o c i a l and p o l i t i c a l issue. Increasing costs of nursing services, heightened consumer s e n s i t i v i t y to the problems of quality--care and a growing government demand that audits or q u a l i t y assurance programs become a c r i t e r i o n f o r h o s p i t a l a c c r e d i t a t i o n a l l contribute to t h i s new focus. Nurse respondents i n a recent survey conducted by nursing leaders i n the U.S. agreed that research r e l a t e d to the i d e n t i f i c a t i o n of components of the q u a l i t y of nursing care be given the highest p r i o r i t y . The q u a l i t y of nursing care has been considered i n r e l a t i o n to nurse s t a f f i n g patterns and i n s e r v i c e education programs (Aydelotte, 1960; New, 1958). 14 The nurses' workload or patient c l a s s i f i c a t i o n l e v e l s have.also been extensively studied but not as they d i r e c t l y r e l a t e to the q u a l i t y of nursing care. A few studies have selected to measure the changes i n the q u a l i t y of nursing care a f t e r introducing primary nursing (Ciske, 1974; Felton, 1975 and Marram, 1976). The e f f e c t of nurse performance'counselling and written goal s e t t i n g on the q u a l i t y of patient care has also been studied (Dyer, 1975). Both studies used d i f f e r e n t q u a l i t y assessment tools but they both found that the q u a l i t y o f nursing care was enhanced with primary nursing and performance counselling. The most extensive research conducted i n order to assess and study the correlates of the q u a l i t y of nursing care was directed by Haussmann, Hagyvary and Newman,(1976). A t o t a l of t h i r t y - t h r e e independent variables were included and the Medicus-Rush Presbyterian q u a l i t y monitoring t o o l . Their findings add support to the e f f e c t s of nursing unit c h a r a c t e r i s t i c s and nursing leadership s t y l e s on enhancing the q u a l i t y of nursing care. These researchers concluded that a smaller s i z e d nursing u n i t , primary nursing and the nurses' favourable perception of the leadership r o l e s i g n i f i c a n t l y e f f e c t e d the q u a l i t y of nurs-ing care. One concern i s that t h i s Medicus study u t i l i z e d measures of question-able v a l i d i t y and r e l i a b i l i t y i n c o l l e c t i n g information about t h e i r t h i r t y - t h r e e independent v a r i a b l e s . Sampling Concepts Considering the state of the a r t of evaluation research i n nursing care whether i t i s process or outcome orientated (Block, 1975), i t i s e s s e n t i a l that the audit be s u f f i c i e n t l y v a l i d , r e l i a b l e and s e n s i t i v e to q u a l i t y d i f -ferences among i n d i v i d u a l s and groups of patients. Group t e s t i n g usually involves a "random" sampling of patients on a number 15 of nursing units of a s t r a t i f i e d sampling of patients with some s p e c i f i e d medical diagnosis. I t i s quite l i k e l y that these sampling techniques l i m i t the v a l i d i t y and meaningfulness of the audit findings f o r nurses and nursing. Neither the medical i l l n e s s model nor the administrative group model seem as appropriate as a nursing diagnoses model (Gebbie and Lavin, 1975). Whether problem patients are "diagnosed" by nurses as e x h i b i t i n g anxiety, manipulation, an a l t e r a t i o n i n (their) l e v e l of cognitive functioning, a lack of understanding Characterized by behaviour inconsistent with one's health condition or non-com-pliance - with therapeutic measures, these nursing diagnoses require nursing action: expressive-instrumental; care-cure-coordination; some independent, some dependent and some interdependent actions. A contrasted or "known groups" approach which i s often advocated i n t e s t i n g the v a l i d i t y and s e n s i t i v i t y of psychological measures seems to have much i n common with the use of tracers i n medical research. To a s s i s t medical researchers i n t h e i r s e l e c t i o n of a research sample of subjects and/or conditions Kessner (1975) developed some sampling c r i t e r i a . A set of s p e c i f i c health p r o b l e m s — c a l l e d tracers—were selected by c r i t e r i a . Considering the purposes of t h i s study i t seemed reasonable to extend t h i s t r a c e r concept into the realms of the psychosocial and thereby encompass sick r o l e deviance, noncompliance and problem patients. According to Kessner the tra c e r design has some established s e l e c t i o n c r i t e r i a : 1) a health problem with a d e f i n i t e functional impact, i . e . intervention by health professionals "makes a dif f e r e n c e " ; 2) a well defined and e a s i l y diagnosed problem; 3) s u f f i c i e n t l y prevalent to permit the c o l l e c t i o n of adequate data from a l i m i t e d population sample; 16 4) the condition or problem under study should be s e n s i t i v e to differences i n the quantity and q u a l i t y of care received by the patient; 5) the technics of prevention, diagnosis, treatment or r e h a b i l i t a t i o n should be well defined; and 6) the e f f e c t s of s o c i a l , c u l t u r a l , economic beha-v i o u r a l and environmental factors should be r e l a t i v e l y well understood and the population at r i s k easy to i d e n t i f y . From the l i t e r a t u r e review there seems to be no d i f f i c u l t y i n e l i c i t i n g nurses' care preferences and t h e i r descriptions of the c h a r a c t e r i s t i c s of t h e i r most and least preferred patients. These findings seem to s a t i s f y the second and t h i r d c r i t e r i a f o r s e l e c t i o n of a tracer sample. There i s a l i m i t e d amount of nursing l i t e r a t u r e to support the f i r s t and fourth tracer c r i t e r i a , i . e . the e f f e c t of nursing interventions with problem patients (Petersen, 1969; Grace, 1974; Zahouret and Morrison, 1974). A f a i r l y indepth analysis of patient-physician problem behaviours i s presented by Gunther (1979). He con-tr i b u t e s s u b s t a n t i a l l y to the understanding, diagnosis, treatment and prevention of the population at r i s k - - t h e problem patient--and therefore o f f e r s some evidence that c r i t e r i a 5 and 6 are also reasonably met. 17 CHAPTER III CONCEPTUAL FRAMEWORK This framework represents an attempt to synthesize the most p o t e n t i a l l y relevant contributing determinants of the q u a l i t y of nursing care. The inter-relatedness of three major components are repeatedly r e f e r r e d to i n the l i t e r a t u r e and these include: the c h a r a c t e r i s t i c s of the stimulus person(s) ( p a t i e n t ( s ) ) , the s e t t i n g c h a r a c t e r i s t i c s ( h o s p i t a l ) , and the c h a r a c t e r i s t i c s of the care provider(s) (nurses). This model incorporates these variables but i n the most part the present research only u t i l i z e s them to e s t a b l i s h a general t h e o r e t i c a l framework f or the t r a d i t i o n a l and current r o l e expectations, b e l i e f s , and values. Some s p e c i f i c objective data about the patient samples and the s e t t i n g c h a r a c t e r i s t i c s were c o l l e c t e d but the main focus was to explore aspects of the a f f e c t i v e domain or nurse perceptions and the nurses' behavioural or. performance dimensions. In one respect the nurses' care preference i s the dependent v a r i a b l e and the nurses' perceptions of the c h a r a c t e r i s t i c s of t h e i r patients can be viewed as independent v a r i a b l e s . The q u a l i t y of nursing care i s the dependent measure. The study model i s presented i n Figure 1 (page 17). In the larger p i c t u r e both the nurses' care preferences and t h e i r per-ceptions of patient behaviours could be viewed as intervening variables between the independent patient-nurse-setting variables and the dependent measure of the q u a l i t y of nursing care. I t i s also possible that nurses' care preferences and t h e i r perceptions of patient behaviours can function as dependent variables FIGURE 1 MODEL OF STUDY VARIABLES: AFFECTIVE AND BEHAVIOURAL RELATIONSHIPS INDEPENDENT PATIENT CHARACTERISTICS. •emographic Socio-Economic Il l n e s s Status Need Status SETTING ... CHARACTERISTICS Init Size Unit Organization NURSE CHARACTERISTICS i Age Education Length of Employment r j > DEPENDENT INDEPENDENT. INDEPENDENT CONFORMING PATIENT BEHAVIOURS High. Preference Low Preference DEVIANT PATIENT BEHAVIOURS DEPENDENT QUALITY OF NURSING CARE A F F E C T I V E B E H A V I O U R 19 i n another study to determine whether the patient-nurse-setting variables i n -fluence nurses'' perceptions and their•preferences. Since most of s o c i o l o g i c a l and nursing l i t e r a t u r e r e f e r s to the i n -fluence of demographic, socio-economic, s o c i o - c u l t u r a l f a c t o r s , and medical diagnosis and prognosis on sick r o l e behaviours, these are included as de-pendent v a r i a b l e s . This model predicts that high preference patients w i l l e x h i b i t conforming/compliant behaviours while the low preference patients w i l l be noncompliant or present sick r o l e deviant behaviours. 20 CHAPTER IV PURPOSES OF THE STUDY This i n v e s t i g a t i o n was undertaken i n order to i d e n t i f y : (1) which pa-t i e n t s the nurses would most and least prefer to give care; (2) what are the nurses' perceptions and behavioural descriptions of these selected patients; and (3) whether these nurse preferences d i f f e r e n t i a l l y influence the q u a l i t y of nursing care received by these most and least preferred patients. Hypotheses 1. Nurses' care preferences are not systematically re l a t e d to demographic patient v a r i a b l e s . 2. Nurses' care preferences are not systematically r e l a t e d to the perceived socio-economic status of the patients. 3. Nurses' care preferences do not systematically vary with the i l l n e s s status of the patients (chronic/acute; prognosis; number of days i n h o s p i t a l ) . 4. Nurses' care preferences are not systematically r e l a t e d to the nursing care need c l a s s i f i c a t i o n of the patients. 5. Nurses' care preferences do not vary with the ratings of patient beha-v i o u r a l d e scriptions. 6. Nurses' care preferences do not systematically a f f e c t the q u a l i t y of nursing care received by the most and least preferred patients. 21 D e f i n i t i o n s In t h i s study nurse and registered nurse (RN) are used interchangeably. Only RNs were involved i n the s e l e c t i o n and ratings of high and low prefer-ence pa t i e n t s . Care Preferences: RNs' s e l e c t i o n of three ward patients f o r whom the majority of nurses on the u n i t , given no other obstacles or duties, would most prefer to care f o r and another three ward patients who would be least preferred. Patient Demographic Variables: Age and sex of patient as stated on t h e i r h o s p i t a l record. Socio-Economic Status: Subjective RN i d e n t i f i c a t i o n of patient education, occupation, and class status (Upper Class, Upper Middle, Middle, Working Class and Lower Cla s s ) . Patient r e l i g i o n was determined from the patient record. I l l n e s s Status: 1) Subjective RN ratings f o r each patient's prognosis—poor, doubtful or good. 2) Subjective RN ratings of whether the patient's i l l n e s s i s chronic or acute. 3) Number of patient days i n the h o s p i t a l . Patient Need Status: 1) Subjective RN ratings of the l e v e l of physical and emotional care each patient r e q u i r e s — h i g h / h i g h ; high/moderate; high/low; low/low; low/moderate; low/high. 2) Summary of Head Nurse's c l a s s i f i c a t i o n of patient needs: Level I, Level II, Level I I I o r Level IV (low high) . 22 Patient Behavioural Descriptors: An evaluative 4-point r a t i n g scale consisting of seventeen p o s i t i v e or compliance/conforming oriented adjectives and nineteen negative or de-viant noncompliance oriented adjectives. Conforming Patient Behaviours: Descriptor scores which load heavily on the seventeen p o s i t i v e / conforming behavioural adjectivesjand low on the nineteen negative behavioural adjectives. Deviant or Nonconforming Patient Behaviours: Descriptor scores which load heavily on the nineteen negative beha-v i o u r a l adjectives and low on the seventeen positive/conforming behavioural adjectives. Quality of Nursing Care: As measured by the Medicus q u a l i t y monitoring t o o l . Group scores are subdivided into four major categories or "Objectives" and twenty-two po t e n t i a l subobjectives. Assumptions The following assumptions underlie the study: The expressed values, attitudes and b e l i e f s o f nurses regarding t h e i r patient preferences can provide valuable information concerning the p r a c t i c e of nursing. The nurses' honest disclosure of patient preferences promotes an aware-ness of i n d i v i d u a l differences and an undertanding of the i n t e r - r e l a t e d -ness of s e l f - s e t t i n g - p a t i e n t i n t e r a c t i o n s . 1. 2. 23 3 . The process oriented Medicus Quality Monitoring Tool i s s u f f i c i e n t l y v a l i d and s e n s i t i v e to measure group differences i n the q u a l i t y of nursing care. 4. The q u a l i t y of nursing care depends upon the performance of some nursing tasks by non-professional or a u x i l i a r y nursing personnel but the profes-si o n a l nurse assigns, i n t e r p r e t s and i s responsible for the completion and q u a l i t y of these a c t i v i t i e s . Therefore, her attitudes and preferences w i l l be "caught" and acted upon by others. 5. That RN care preferences i s a continuous variable with a s t a t i s t i c a l l y normal d i s t r i b u t i o n . . Limitations L. Purposive sampling as used i n t h i s study r e s t r i c t s a generalization to larger populations (Abdellah and Levine, 1965). 2. The s e l e c t i o n of study patients by the RNs based on "A majority" opinion does not permit measurement or control of i n d i v i d u a l differences i n nurse perceptions or performance. 3 . The Medicus Quality Monitoring Tool i s designed as a ser i e s of 25* d i f f e r e n t worksheets which are to be used i n sequence. The patients i n the study therefore receive d i f f e r e n t questionnaires and an i n d i v i d u a l analysis i s not v a l i d or r e l i a b l e . Only group scores can be used i n the analysis of the q u a l i t y of nursing care. *Only nine d i f f e r e n t worksheets were used i n t h i s study. 4. A f i e l d study design with i t s concomitant lack of control over most extrane-ous variables threatens both the i n t e r n a l arid, external v a l i d i t y of the study. 24 CHAPTER V METHODOLOGY ( This chapter describes the p i l o t study, the sampling and data c o l l e c t i o n process, the instruments and the data analysis procedures. P i l o t Study Considering the large number of unknowns i n t h i s study some preliminary te s t i n g was necessitated. A medical nursing u n i t that was not i n the study sample was used to p i l o t the sampling technique, the patient s o c i a l data sheet, and the patient Descriptors Rating Scale. The f e a s i b i l i t y of including a non-participant observation technique f or measuring the q u a l i t y of nursing care was also explored. The nurse p a r t i c i -pants i n the p i l o t study included: one head nurse, ten RNs and three LPNs. The f i r s t study concern was the s e n s i t i v i t y and possible reluctance of nurses to admit to the researcher that they or t h e i r colleagues did view some patients as most preferred and le a s t preferred. I t was necessary to ascer t a i n the degree of nurse agreement or disagreement regarding p a t i e n t - s p e c i f i c care preferences. In an informal interview s i t u a t i o n , each p a r t i c i p a t i n g nurse was asked to sel e c t three high preference and three low preference patients presently on t h e i r ward. Instructions were standardized and nurses were asked to respond to the following statements: 25 Part 1. Given the opportunity to f r e e l y choose your patient assignment you would: Most prefer to care f o r : Name 1. 2. 3. B. Least prefer to care f o r : Name 1. 2. 3. Part 2. Given the opportunity to f r e e l y choose a patient assignment most  of the nurses on your ward would: A. Most prefer to care f o r : Name B, Least prefer to care f o r : Name 1. 2. 3. 1. 2. 3. Only the Head Nurse expressed verbal doubts and concerns about the naming of the le a s t preferred patients. The RNs and LPNs were most keen'to o f f e r t h e i r opinions and offered more information about the patients than was r e -quested. They also reported that i t was much easier to choose the low pre-ference patients than the high preference patients. The se l f - o t h e r r a t i n g differences were quite pronounced. Some of the "others" l e a s t preferred patients were the most preferred by an i n d i v i d u a l nurse respondent. There was also a differe n c e between the ratings of RNs and LPNs. The RNs as Team Leaders admitted that they were somewhat removed, or could remove themselves, from regular and d i r e c t contact with the le a s t preferred patients whereas the LPNs did not have as much "avoidance opportunity" since they were required to perform most of the physical care and routine patient treatments and procedures. Nursing care preferences could be the r e s u l t of many fa c t o r s . In th i s study the s e l e c t i o n of patient c h a r a c t e r i s t i c s included demographic and socio-26 economic data, patient care needs and some associated i l l n e s s data. A patient behaviour r a t i n g scale was also tested. Results showed that most of the nurses knew l i t t l e about t h e i r patients' socio-economic status and did not base t h e i r care preferences on the l e v e l of physical or emotional care required by the selected patients. Patient behavioural descriptor ratings were strongly r e l a t e d to the nurses' patient preference r a t i n g s . The le a s t preferred patients loaded heavily on.the nonconforming si c k r o l e descriptors whereas the most preferred patients were rated high on the conforming de s c r i p t o r s . The f e a s i b i l i t y of using a non-participant observation technique to supple-ment the Medicus q u a l i t y monitoring instrument was rejected. A two-hour patient observation period yielded too few nurse-patient interactions to a r r i v e at a meaningful nursing q u a l i t y score. On the average there were only ten minutes of d i r e c t nurse-patient i n t e r a c t i o n during the two-hours of observation. The p i l o t study demonstrated that the sample technique and the patient descriptors scale were accepted and understood by the nurse p a r t i c i p a n t s . There was also evidence that the nurses were consistent i n t h e i r perception of the u n i t nurses' care preferences and i n t h e i r patient behavioural r a t i n g s . The obtrusiveness and p o t e n t i a l s e n s i t i v i t y and r e a c t i v i t y of the measures did not seem to e f f e c t the nurses' response. The findings from the p i l o t study were reviewed with the Head Nurse of the Unit and suggestions f o r the implementation of p r a c t i c e changes were con-sidered. A l l of the nurse p a r t i c i p a n t s f e l t that the study findings had offered them a p o s i t i v e stimulus and challenge. 27 Data C o l l e c t i o n Selection of Nursing Units Four medical nursing units i n a large metropolitan teaching h o s p i t a l were selected f o r the study. The c o l l e c t i o n of the data f o r t h i s study was coordinated with an on-going q u a l i t y assurance program i n the h o s p i t a l . The study design was explained to the head nurses, supervisors, and nursing administrators. Since the inves t i g a t o r was employed i n a research /position i n the medical nursing department at the time of data c o l l e c t i o n many of the nursing personnel had previous p a r t i c i p a n t experience. Although there was considerable v a r i a b i l i t y i n the range of medical s p e c i a l t y services offered on each of the study u n i t s , there was no evidence that the nursing p r a c t i c e s or p o l i c i e s on the units were s i g n i f i c a n t l y d i f f e r e n t . The siz e of the units did d i f f e r : the smallest u n i t had eighteen patients followed by units with thirty-two, t h i r t y - s i x and f o r t y - f o u r patients r e s p e c t i v e l y . Over the three months of data c o l l e c t i o n each of the study units was sampled on four or f i v e d i f f e r e n t occasions. The patient sample s i z e per un i t was mainly determined by the requirements of the Medicus q u a l i t y monitor-:, ing t o o l . For each of the four sampled nursing u n i t s the RNs were requested to select ten high preference patients and ten low preference patients. Selection of Nurse Sample The s i z e of the nursing unit determined whether two or four RNs were selected from each u n i t . The Head Nurse on the day p r i o r to the q u a l i t y monitoring selected the RN p a r t i c i p a n t s . A t o t a l of t h i r t y - t h r e e nurses p a r t i c i p a t e d i n the study. The s e l e c t i o n c r i t e r i a were as follows: 28 1. S i g n i f i e d willingness to p a r t i c i p a t e i n the study by signing the consent form. A sample i s presented i n Appendix C. 2. S u f f i c i e n t knowledge about the patients on t h e i r Unit to complete the patient behaviour descriptor r a t i n g scale. 3. Could be freed from t h e i r regular nursing duties f o r t h i r t y to f o r t y - f i v e minutes to complete the patient r a t i n g s . On a few p a r t i c u l a r l y busy days on a Nursing Unit or when many of the regular s t a f f nurses were not on duty only one or two RNs were av a i l a b l e to p a r t i c i p a t e i n the study. According to the standardized i n s t r u c t i o n ^ RN p a r t i c i p a n t s were requested to choose three (or four) most preferred patients and three (or four) least preferred patients. Each nurse'completed t h e i r patient s e l e c t i o n independently. Their responses were then compared. On only two occasions did the nurses' s e l e c t i o n not agree and a "negotiating" discussion was allowed u n t i l agreement was reached. The patient names and room numbers were then given to the researcher without any reference to t h e i r preference status. The backside of the Adjective Descriptor l i s t included a space f o r the RN's unstructured response about the reasons or r a t i o n a l e for each of the patients' high or low preference s e l e c t i o n . A f t e r completion of the demographic, socio-economic and i l l n e s s r e l a t e d patient data each RN completed an Adjective Descriptors Rating Scale f o r e'ach selected patient. A l l RN responses and ratings were completed independently and not reviewed by the inv e s t i g a t o r . As presented i n the P i l o t Study Part II i n s t r u c t i o n s . 29 Selection of Patient Sample Each selected patient was approached by the i n v e s t i g a t o r i n order to obtain t h e i r consent to p a r t i c i p a t e i n the study (See Appendix C). A l l of the selected patients, or t h e i r f a m i l i e s , gave t h e i r consent. It seemed that t h i s was l a r g e l y due to the researcher's employed status i n the h o s p i t a l but i t was also apparent that many patients f e l t obliged and signed t h e i r con-sent without reading i t . Those patients who were unable to give t h e i r consent and d i d not have any v i s i t i n g friends or family were included i n the study on the basis of the u n i t nurses' consent. A t o t a l of eighty patients were study subjects: f o r t y high preference and f o r t y low preference patients. The physicians of the selected patients received written information regarding the study purposes. A sample i s included i n Appendix C. The information form was placed on the outside cover of each patient's chart. Only four physicians responded and none of them was c r i t i c a l of the study. Instruments Adjective Descriptor Rating Scale The adjectives which are most often used to describe p o s i t i v e and negative patient behaviours have been r e f e r r e d to i n the l i t e r a t u r e and i n r e l a t e d nursing studies. An-instrument that i s composed l a r g e l y of adjectives was developed by Rich and Dent (1962). They believed that adjectives were more l i k e l y to y i e l d a measure of the emotional components of interpersonal a t t i -tude's:. The; reported r e l i a b i l i t y of the scale was .73 to .89 f o r t e s t - r e t e s t ; ,77 tp .94 f o r s p l i t - h a l f and a much lower i n t e r - r a t e r r e l i a b i l i t y of .41 to 30 .77. I n t e r - r a t e r differences are to be expected when each nurse i s asked to respond to the items according to her i n d i v i d u a l values, b e l i e f s and perceptions. From past experience and discussions with colleagues eleven descriptors were added to the Rich and Dent Scale and one was omitted. This researcher : f e l t that the frequency with which "timid" was used as a patient descriptor was so low that i t was d i f f i c u l t to integrate i t into a conceptual framework. The added descriptors were mainly based on findings from other studies and included: considerate, i n t e l l i g e n t , t r u s t i n g , manipulative, undemanding, anxious, a problem patient, l a r g e l y responsible f o r present i l l n e s s , angry, h e l p f u l and overly dependent--could do more for s e l f . Each o f the t h i r t y - s i x . adjectives was typed on a card and s i x expert 2 judges were asked to sort them into a good patient or problem patient descrip-t i o n using the "most t y p i c a l or usual nurse a t t i t u d e " as t h e i r frame of reference. The s i x sorts were i d e n t i c a l but some questions did a r i s e regarding the evalua-t i v e relevance of two of the a d j e c t i v e s — i n t e l l i g e n t and anxious. The format of the patient Adjective Descriptor Rating Scale i s presented i n Figure 2. Patients' Socio-Economic and I l l n e s s Related Information Additional information regarding the nurses' perceptions (or knowledge) of the selected patients was included i n the data c o l l e c t i o n . These items r e f e r r e d to the patient's p h y s i c a l and emotional care needs, his prognosis, acuity, education, occupation and class status and i s presented i n Figure 3. The judges were a l l employed i n the study h o s p i t a l i n the positions of: 2 Mental Health Nurse C l i n i c i a n s ; 1 Diabetic Nurse C l i n i c i a n ; 2 Medical Head Nurses; 1 Nurse Research Assi s t a n t . 31 FIGURE 2 ADJECTIVE DESCRIPTORS RATING SCALE Place,a check mark (/) for each word i n the column which seems the most appro-p r i a t e perception of t h i s patient's usual behaviour from the viewpoint of most of the ward nurses. PATIENT'S NAME: DATE: NUMBER OF DAYS OF HOSPITALIZATION: WARD: DESCRIBES PATIENT -> VERY WELL SOMEWHAT A LITTLE NOT AT ALL 1. Cooperative 1 2. Grouchy 2 3. R e l i a b l e 3 4. Easy to please 4 5. A model patient 5 6. Considerate 6 7. Appreciative 7 8. A nuisance 8 9. Sincere 9 10. Gossipy 10 11. Chronic complainer 11 12. I n t e l l i g e n t 12 13. Obedient 13 14. Trusting 14 15. Attention seeking 15 16. Manipulative 16 17. Apathetic 17 18. Undemandi ng 18 19. Anxious 19 20. F r i e n d l y 20 21. Over reacts 21 22. Good 22 23. U n s e l f i s h 23 24. Untidy 24 25. C h i l d i s h 25 26. Optimistic 26 27. Asks too many questions 27 28. A problem patient 28 29. H o s t i l e 29 30. Largely responsible for present i l l n e s s 30 31. Withdrawn 31 32. Interested i n getting well 32 33. Angry 33 34. Helpful 34 35. Overly dependent--could do more f o r s e l f 35 36. Confused 36 32 FIGURE 3 DEMOGRAPHIC, SOCIO-ECONOMIC AND ILLNESS-RELATED DATA SHEET Preference Rating: HIGH LOW Reason(s) f o r above r a t i n g : Physical Care Needs: HIGH MODERATE LOW Emotional Care Needs: HIGH MODERATE LOW Diagnosis: Prognosis: _ _ _ _ _ _ _ _ DETERIORATED (POOR) UNCHANGED (DOUBTFUL) IMPROVED (GOOD) Does the patient have a family? YES NO Acuity: LONG TERM SHORT TERM Do the family v i s i t ? YES Do the family cooperate with the nurse? Patient Education: Patient Age: NO DON'T KNOW FREQUENTLY YES NO OCCASIONALLY SOMETIMES Patient Occupation: Socio-Economic Status: UPPER CLASS UPPER MIDDLE CLASS MIDDLE CLASS WORKING CLASS . LOWER CLASS Is t h i s patient l i k e l y to consent to p a r t i c i p a t e ? YES NO Room accommodation: PRIVATE SEMI-PRIVATE PUBLIC Names of patients i n the room: 33 Patient Needs C l a s s i f i c a t i o n The Medicus Quality Monitoring worksheets, were generated to take into account the degree of patient dependency on nursing care. Four le v e l s are recognized: .Level I requires minimal nursing care while Level IV requires intensive nursing care. This patient c l a s s i f i c a t i o n form i s completed d a i l y by each Head Nurse or her delegate. The major categories r e f e r to patient needs f o r : n u t r i t i o n , elimination, oxygen, a c t i v i t y , s e c u r i t y and s e l f -concept. The various needs have d i f f e r e n t weightings from three to s i x points. The point sum of a l l the patient needs indi c a t e the l e v e l of nursing care required by the p a t i e n t . A Level I patient i s a patient with a point sum of zero to eleven; Level II from twelve to twenty-seven; Level III from twenty-eight to f i f t y - t w o ; and Level IV at f i f t y - t h r e e or greater. The point c l a s s i -f i c a t i o n form with the i n d i v i d u a l weightings of the patient need levels appears i n Appendix D. < Quality of Nursing Care Scale The o r i g i n a l study proposal incorporated the use of two measures of the q u a l i t y of nursing care. The non-participant observation approach to the measurement of the q u a l i t y of nursing care i s the process required to use the Quality Patient Care Scale (Wandelt, 1970) . Direct observation of nursing care gives performance information that may be missed i n a patient chart review or i n interviews. The second q u a l i t y measure i n t h i s study was the Medicus Quality Scale which was already i n wide use i n the study h o s p i t a l . The Medicus instrument i s — c o n s i d e r i n g the "state of the art"--reputed to be the most tested tool f o r measuring the q u a l i t y of nursing care. Although v a l i d i t y and r e l i a b i l i t y 34 scores are not reported i n the l i t e r a t u r e the developers state that the metho-dology has "proven r e l i a b i l i t y and v a l i d i t y " (Medicus Systems Corporation, n.d.; Haussmann, Hegyvary, Newman, 1976). The methodology takes a patient-oriented approach to the evaluation of nursing care. Two concepts that form the basis of t h i s approach are nursing process and patient needs. Patients are c l a s s i f i e d as Type I, I I , III or IV which r e l a t e to the patient's l e v e l of s e l f - s u f f i c i e n c y . Observation work-sheets are generated by patient type. A master l i s t of two hundred f i f t y -seven c r i t e r i a has been prepared and the abbreviated format i s as follows. Objective and Subobjective Structure 1.0 Plan of Nursing Care i s formulated. 1.1 -> 1.5 subobjectives r e f e r to admission assessment, current assess-ment and a written nursing care plan which i s coordinated with the medical plan of care. 2.0 Physical Needs are attended. 2.1 Protection from i n j u r y 2.2 Physical.comfort and r e s t 2.3 Physical hygiene 2.4 Need for oxygen 2.5 A c t i v i t y 2.6 N u t r i t i o n and f l u i d s 2.7 E l i m i n a t i o n 2.8 Skin Care 2.9 Protection from i n f e c t i o n 3.0 Non Physical (Psycho-social) Needs are attended. 3.1 -»• 3.6 subobjectives include admission o r i e n t a t i o n to h o s p i t a l routines and f a c i l i t i e s , s o c i a l courtesy, privacy and c i v i l r i g h t s , psycholo-g i c a l well-being, health teaching and family involvement. 4.0 Nursing Care Objectives are evaluated. 4.1 Documentation of care 4.2 Patient response to therapy i s evaluated For this'study only these four objectives were measured. The complete outline of the s i x objectives and subobjective structure i s presented i n Appendix E. 35 Each q u a l i t y monitoring worksheet contains a section r e f e r r i n g to informa-t i o n which i s obtained from (1) the patient chart or kardex; (2) observation of the patient; (3) the environment; (4) patient interview; and (5) nurse interview. One of the twenty-five worksheets i s presented i n Appendix F. The established Medicus Computer Program produces q u a l i t y indices for the twenty-eight subobjectives. The scores for each subobjective: are the average of the c r i t e r i o n scores within the subobjective. Indices f o r major objectives are computed as average values of the subobjective scores within a given objective. The methodology measures the q u a l i t y of care f o r a group of patients for a circumscribed period of time; i t does not measure the q u a l i t y of care for each i n d i v i d u a l patient. Data Coding and Analysis Procedures This section describes the methods for coding the information about the RN and patient p a r t i c i p a n t s and for scoring and tabulating the reponses to the descriptor scale and q u a l i t y of nursing scale. S t a t i s t i c a l techniques for the t e s t i n g of s i g n i f i c a n t differences between patient groups i s also pre-sented. A 0.5 l e v e l of s i g n i f i c a n c e was selected as the c r i t i c a l value for th e . r e j e c t i o n of the n u l l hypotheses. Information About the RN P a r t i c i p a n t s Data r e l a t e d to the RNs' education program,,their ages and length of em-ployment was c o l l e c t e d . Frequencies, means and ranges were tabulated for each category. 36 RN Education Program data was c o l l e c t e d under three categories: Bacca-laureate, Hospital diploma or College diploma. Ages were also grouped: 1) less than twenty-five years of age; 2) between twenty-five and t h i r t y - f i v e years; and 3) greater than t h i r t y - f i v e years. Length of employment included: less than one year; one to three years; and more than three years. Information About the Patient Sample The patient age and sex were the only objective demographic data that were analyzed. Since sex i s a nominal v a r i a b l e , a cross tabulation between the high and low preference patient groups and sex was performed and tested f o r s i g n i f i c a n c e using the Chi-Square. The s i g n i f i c a n c e of age differences-between the patients i n each preference group was computed using a t - t e s t . Only the RN respondents' subjective ratings of the patient education and occupation were analyzed. Two categories for each of the s o c i a l status cate-gories were chosen: know and don't know. Frequency scores were calc u l a t e d . RN subjective ratings of a patient's class status were also included. Again only frequency scores for each group were computed. The patient's stated r e l i g i o n was obtained from the patient chart, and the d i s t r i b u t i o n of frequencies f o r the four c a t e g o r i e s — P r o t e s t a n t , Catholic, Hebrew and Other--was calculated. The RNs' subjective response to the question about the patient prognosis and acuity was also analyzed using the frequencies of RN response f o r each patient group. Prognosis included three categories: good, doubtful, poor; while acuity had two categories: long term and short term i l l n e s s . The patient group differences r e f e r r i n g to the number of days i n the hos-p i t a l and the l e v e l of nursing care required were ca l c u l a t e d using the t - t e s t . 37 The RNs' perceived ratings f o r each patient's emotional care needs and teaching needs were cross tabulated with the patient preference group member-ship. Group differences were calculated using the Chi-Square s t a t i s t i c . Analysis of the Adjective Descriptors Rating Scale RNs responded to each adjective on a four point scale: describes the patient very well (four p o i n t s ) ; describes the patient somewhat (three p o i n t s ) ; describes the patient a l i t t l e (two p o i n t s ) ; and describes the patient not at a l l (one p o i n t ) . Rich and Dent (1962) had recommended that the p o s i t i v e der s c r i p t o r s be scored from+3 to 0 and negative descriptors from -3 to 0. The simpler s c a l i n g technique i s recommended by Edwards and L i k e r t . L i k e r t found that scores based on this method correlated .99 with the more complicated system of normal deviate weighting of items (Edwards, 1957). The two RN ratings f o r each patient were averaged for each of the t h i r t y -s i x d e scriptors. A mean descriptor score f o r the high preference group of patients and low preference patients was also obtained. An omitted response by one of the RNs was scored as a zero but included i n the computation of mean scores and i n the subsequent computation of the discriminant function. The RNs' explanations f o r omissions were that they lacked that information about a patient's behaviour or a t t i t u d e . Omissions occurred very infrequently--only f o r t y - e i g h t times i n 4,652 responses--and, no systematic pattern was i d e n t i f i e d . Only s i x of the 132 ratings contained one or more zeros. For the high preference and low preference patient groups there were twenty-five and twenty-three instances of an omitted d e s c r i p t o r response. Since there were some occasions when two RNs were not av a i l a b l e to complete 38 the patient ratings the discriminant analysis was computed using 132 patients' ratings. Fourteen high preference and fourteen low preference patients re-ceived only one RN r a t i n g . S i x t y - f i v e percent or f i f t y - t w o of the eighty selected patients were rated by two RNs; twenty-eight patients were rated by only one RN. The r e l a t i o n s h i p between the RN patient-preference s e l e c t i o n and the a t t r i b u t e d patient behaviours was ascertained by a discriminant function analy-s i s . Kerlinger (1964) and Kerlinger and Pedhauzer (1973) describe the discrim- -inant function as a regression equation with a dependent variable that represents group membership:, e.g. Y Q = X + X 2 . . . X 3 & + C; Y 1 = X 1 + X 2 . . . X 3 6 +.C. With two or more independent variables (Adjective Descriptors) and the members of two groups (high and low preference patients) the discriminant function gives the best p r e d i c t i o n of the correct group membership of each member of the sample. The patient descriptor ratings were used as the independent or c r i t e r i o n variables i n order to i d e n t i f y the extent to which they predicted patient'membership i n e i t h e r the high or low preference group. The 1975 S t a t i s t i c a l Package f o r the S o c i a l Sciences (SPSS) computer pro-gram was used for t h i s analysis. Analysis of the Quality of Nursing Care Scale A two way analysis of variance was performed. The two independent variables were: preference group (high and low) and the four nursing care categories or Objectives i n the q u a l i t y r a t i n g scale. The q u a l i t y scores were the depen-dent v a r i a b l e s . The r e s u l t s were analyzed using the thirty-two grouped scores since i n d i v i d u a l q u a l i t y scores are neither v a l i d nor r e l i a b l e due to the v a r i a b i l i t y i n the questionnaires or monitoring work sheets. 39 A one-way analysis of variance was also conducted so that differences i n scores among the four Objectives and the preference group could be ascertained. The four Quality Objectives analyzed were: 1) Care Plan; 2) Physical Care; 3) Psychosocial Care; and 4) Evaluation of Plan and Patient Response. The means and standard deviations for each group and each q u a l i t y objective were also computed. Summary of the Data Analysis Procedures Data was analyzed i n order to t e s t the s i x study hypotheses. 1) A discriminant function analysis would determine whether the Adjective Descriptor ratings were good predictors of the RNs' high and low pre-ference ratings. 2) A two-way analysis of variance would i d e n t i f y whether RN care preferences influenced the q u a l i t y of nursing care. Since q u a l i t y of nursing care i s a multidimensional phenomenon, a subsequent one-way analysis of variance was needed to i d e n t i f y whether a s p e c i f i c nursing care dimension (or q u a l i t y objective) contributed d i f f e r e n t i a l l y to differences i n the q u a l i t y of nursing care between the high and low patient preference groups. 3) Because some of the control variables such as patient age, number of days i n the h o s p i t a l and the patient c l a s s i f i c a t i o n or the l e v e l or re-quired nursing care were measured as continuous v a r i a b l e s , differences between the two patient groups were analyzed using the student t - t e s t . 4) A number of control variables were only measured on a nominal-scale. These include sex, emotional and teaching needs, and a Chi-Square was used to t e s t group dif f e r e n c e s . 5) The remaining patient variables such as prognosis, acuity of i l l n e s s , 40 education, occupation and.class status, are presented as frequencies of the RN responses. 6) Data describing the RN p a r t i c i p a n t s i s presented i n frequency tables and were not subjected to s t a t i s t i c a l t e s t i n g . 41 CHAPTER VI FINDINGS This chapter has four sections. The f i r s t section describes some general responses of the p a r t i c i p a n t s i n the study; the second section describes the c h a r a c t e r i s t i c s of the study p a r t i c i p a n t s . Section three includes the findings from the Adjective Descriptor Rating Scale and the l a s t section presents the findings from the q u a l i t y of nursing care r a t i n g s . General Responses of the P a r t i c i p a n t s Toward The Study The majority of RNs who were asked to p a r t i c i p a t e were exceedingly co-operative i n a s s i s t i n g with the s e l e c t i o n of patients as well as completing the r a t i n g scales. Their willingness to take time f o r t h i s task, imposed upon an already busy schedule, was impressive. Not only were they w i l l i n g to p a r t i c i p a t e , but they were most in t e r e s t e d i n learning the r e s u l t s . Most of the RNs v o l u n t a r i l y expressed, somewhat embarrassedly, that i t was much easier to s e l e c t the low preference patients than the high preference patients. They a t t r i b u t e d t h i s to the f a c t that "problem" patients were more often discussed among the s t a f f and mentioned during s h i f t reports and were, therefore, better known. A few RNs f e l t there was some d i f f i c u l t y i n d i f f e r e n t i a t i n g between the two c l a s s i f i c a t i o n s of "Somewhat" and "A l i t t l e " i n the Adjective Descriptor Rating Scale. Some Head Nurses voiced t h e i r concern that some of the study patients would not give v a l i d responses. To quote, "You can only believe h a l f of what he/she says." "Complains about everything!" and "You'll get an e a r f u l from him/her'." The majority of the patients who were approached responded favourably to the purposes of the study. Many of the patients i n the low preference group read the consent c a r e f u l l y , asked further questions, and gave free vent to t h e i r f e e l i n g s about h o s p i t a l s , doctors and nurses. Some of these patients were hesitant to p a r t i c i p a t e but none withdrew from the study. Those patients i n the high preference group hardly glanced at the consent form before signing i t . The researcher then stressed the importance of knowing the contents of the consent and i n several instances, read i t i n f u l l to the patient. This patient acquiescence was f a m i l i a r patient behaviour but s t i l l d isconcerting to the researcher. A number of other studies have reported s i m i l a r f i n d i n g s . Tagliacozzo and Mauksch found that when patients were d i r e c t l y asked what they considered t h e i r r i g h t s to be, they had d i f f i c u l t i e s i n responding. They reported that "One fourth of the respondents admitted that they did not know what t h e i r r i g h t were; some patients stated outright that they had no r i g h t s . The majority of respondents l i m i t e d themselves to general answers such as 'good care'." From a U.S. survey of more than 2,000 families or 5,340 persons, Suchman (1972) reports that eighty-one percent of the respondents agreed with the state ment, "When I am i l l I demand to know a l l the d e t a i l s of what i s being done to me". For those respondents who were h o s p i t a l i z e d during the study period some eighty-nine percent reported that no one at any time bothered to explain the h o s p i t a l routines to them. Suchman contrasts t h i s f i n d i n g with the generally reported favourable patient attitudes towards the h o s p i t a l care. He suggests 43 that these differences may be due to the low l e v e l of patient expectation. A s i m i l a r theme forms the focus of a study by Seeman and Evans (1962) . They conclude that a patient who f e e l s "alienated"; i . e . one who f e e l s a general sense of powerlessness or lack of personal control i s less i n c l i n e d to seek information. The non-questioning behaviours of the high preference patient group i n t h i s present study may be a response to t h e i r feelings of a l i e n a t i o n or power-lessness. This i s i n contrast to the general high degree of questioning and information seeking attitu d e of the low preference patient group. In l i n e with Seeman and Evans' t h e s i s , these low preference patients demonstrate a low l e v e l of a l i e n a t i o n and a strong b e l i e f i n t h e i r own capacity to control events. C h a r a c t e r i s t i c s of the Participants Description of the Nurses The nurses i n the sample were r e l a t i v e l y heterogeneous with respect to the data that was c o l l e c t e d about them. The tabulation of nurse c h a r a c t e r i s t i c s i s presented i n Table I. F i f t y - f i v e percent of the t h i r t y - t h r e e nurses were under twenty-five years of age; t h i r t y - s i x percent were between twenty-five and t h i r t y - f i v e ; and nine percent were over t h i r t y - f i v e . Nineteen RNs had less than one year experience i n nursing; eight had less than three years and s i x had more than three years. Educational backgrounds i n nursing also varied with eight baccalaureate gra-duates, eight h o s p i t a l diploma school graduates and seventeen graduates from a two-year college program. For each of the sample nursing units the selected RNs seem to be evenly d i s t r i b u t e d by educational program, age and length of 44 TABLE I DISTRIBUTION OF RN CHARACTERISTICS BY UNIT, NURSING EDUCATIONAL PROGRAM, AGE, AND LENGTH OF EXPERIENCE IN NURSING Educational Program Age (Years) Length of Nursing Nursing Hosp C o l l Employr tient (Yea: -s) Unit BSN Dip Dip <25 25-35 >35 <1 1-3 >3 N n n n n n n n n n A 9 2(22) '2(22) 5(56) 3(33) 5(56) 1(H) 4(44) 3(33) 2(22) B 9 3(33) 3(33) 3(33) 7(78) 2(22) 0(0) 7(78) 2(22) 0(0) C 9 1(11) 2(22) 6(66) 5(56) 2(22) 2(22) 5(56) 1(11) 3(33) D 6 11(33) 1(17) 3(50) 3(50) 3(50) 0(0) 3(50) 2(33) 1(17) T i. O t. 33 8(24) 8(24) 17(52) 18(55) 12(36) 3(9) 19(58) 8(24) 6(18) * Percentages are bracketed numbers. employment i n nursing. Description of the Patients  Demographic Data The patients who were selected as high preference or low preference were s i m i l a r with respect to the demographic data that was c o l l e c t e d . There were seventeen males and twenty-three females i n the low preference group and nineteen males and twenty-one females i n the high preference group. The Chi-Square was 0.82 and not s i g n i f i c a n t . Nearly one h a l f of the patients were over s i x t y - f o u r years of age with l i t t l e d ifference between the two groups; forty-two percent and forty-seven percent r e s p e c t i v e l y . Twelve low preference patients were between f o r t y - f i v e and s i x t y - f o u r years of age compared to ten. of the high preference p a t i e n t s . The "34 years or under" age bracket showed a s i m i l a r pattern; eight low prefer-45 ence and ten high preference. The t e s t i n g f o r group differences by the t - t e s t indicates that the two groups were indeed s i m i l a r with regard to t h e i r age d i s t r i b u t i o n . Table II presents the t - t e s t values. TABLE II PATIENT AGE DIFFERENCES BETWEEN THE TWO PREFERENCE GROUPS: T-TEST Preference  Group Low High N Mean S. ,D. t-Value df 40 57.38 22. .27 -0.18 78 40 58.25 21. .61 2-Tailed  P r o b a b i l i t y 0.86 The s i m i l a r i t y between the group means and group standard deviations i s apparent. Based on these two demographic v a r i a b l e s — p a t i e n t sex and age—the f i r s t study hypothesis i s accepted. These va r i a b l e s , therefore, do not influence RN s e l e c t i o n of high or low preference patients. Socio-Economic Data C l a s s i f i c a t i o n according to patients' socio-economic status was based on RN perception's or knowledge of patient education, occupation and cla s s standing. The "status" of the selected patients was not known by the major-i t y of RN p a r t i c i p a n t s . For the patient education category, the RN respondents indicated that they " d i d not know" f o r eig h t y - f i v e percent of the low preference patients and ninety-one percent of the high preference patients. The patients' occu-pation was not known for seventy percent and f i f t y - e i g h t percent of the low and high preference patients r e s p e c t i v e l y . r 46 The RNs' estimation of the patients' class status received more "know" responses. Only eight percent of the low preference group and f i f t e e n per-cent of the high preference group were not given a class r a t i n g . The largest number of patients f o r each group were c l a s s i f i e d as middle c l a s s : forty-one percent f o r low and t h i r t y - e i g h t percent f o r high preference patients. The next larges t category was working class with t h i r t y - s i x percent of the RN ratings i n the low preference 'and twenty-six percent i n the high preference patient group. The RNs' knowledge of the patients' socio-economic status does not i n d i -cate that these a t t r i b u t e s were considered i n t h e i r s e l e c t i o n of high or low preference patients. Tables I I I , IV and V present the frequency d i s t r i b u t i o n s for each patient group. TABLE III FREQUENCY DISTRIBUTION FOR PATIENT PREFERENCE GROUP AND RN PERCEPTION OF PATIENT EDUCATION Preference  Group N Know RN.Perceptions Don't Know Low 66 10(15) 56(85) High 66 6(9) 60(91) Totals 132 16(12) 116(88) Brackets indicate percentages. 47 TABLE IV FREQUENCY DISTRIBUTION FOR PATIENT PREFERENCE GROUP AND RN PERCEPTION OF PATIENT OCCUPATION Preference RN Perceptions  Group N* Know Don't Know Low. 66 20(30) 46(70) High 66 28(42) 38(58) Totals 132 48(36) 84(64) Brackets indicate percentages. TABLE V FREQUENCY DISTRIBUTION FOR PATIENT PREFERENCE GROUP AND RN PERCEPTION OF PATIENT CLASS STATUS Preference RN Perceptions  Group N* High Hi-Middle Middle Working Low _? Low 66 2(3) 7(11) " 27(41) 24(36) 1(2) 5(8) High 66 0(0) 11(17) 25(38) 17(26) 3(5) 10(15) Totals 132 2(2) 18(14) 52(39) 41(31) 4(3) 15(11) Brackets indicate percentages. *I d e a l l y each patient would have received ratings by two nurses r e s u l t i n g i n an N of 80 per patient group—and a t o t a l of 160 rat i n g s . Due to circum-stances r e f e r r e d to on p. 28, the t h i r d c r i t e r i o n f o r nurse p a r t i c i p a t i o n could not be met and only one nurse was av a i l a b l e to do the pa t i e n t - r a t i n g s . As mentioned on p. 38, fourteen high preference and fourteen low preference patients received ratings by only one nurse. Sixty f i v e percent or 52 of the 80 selected patients were rated by two nurses. The t o t a l number of ratings i s therefore 132 (52 + 52 + 28) rather than the planned 160 rat i n g s . 4.8 The three major r e l i g i o u s f a i t h s were represented. There were nineteen low preference Protestant patients and twenty-high preference Protestant pati e n t s ; f i v e low preference Catholic patients and four high preference Cath o l i c s ; one low preference Hebrew patient and two high preference Hebrew patients. One "other" category was included to represent those patients with no r e l i g i o n ,or some d i f f e r e n t f a i t h s . This category was recorded for f i f t e e n of the low preference patient group and fourteen of the high preference group. A frequency d i s t r i b u t i o n appears i n Table VI. TABLE VI FREQUENCY DISTRIBUTION FOR PATIENT PREFERENCE GROUP AND PATIENT RELIGIOUS CLASSIFICATION Preference Religious C l a s s i f i c a t i o n Group N Protestant Catholic Hebrew Other Low 40 19(48) 5(12) 1(2) 15(38) High 40 20(50) 4(10) 2(5) 14(35) Totals 80 39(49) 9(11) 3(4) 29(36) Brackets indicate percentages. These findings suggest that RN care preferences are not r e l a t e d to the perceived socio-economic status of the patient. Therefore the second study hypothesis i s also accepted. The degree to which the nurses did not have knowledge about t h e i r patients' socio-economic status i s d e f i n i t e l y a challenge to the professed professional nursing b e l i e f s . Contrary to Larson's 1977 study, the nurse p a r t i c i p a n t s i n t h i s study d i d not demonstrate that patient preferences were-:-in. any way--49 r e l a t e d to the socio-economic status of the patient. I l l n e s s Data I l l n e s s r e l a t e d data was c o l l e c t e d from a number of sources. Patient prognosis and acuity data was based on RN perceptions. Table VII presents the frequency d i s t r i b u t i o n s of i l l n e s s status between the high and low patient preference groups. TABLE VII FREQUENCY DISTRIBUTION FOR PATIENT PREFERENCE GROUP AND RN PERCEPTIONS OF PATIENT ILLNESS STATUS Preference RN Perceptions: I l l n e s s Status Group N Prognosis Acuity Low. High 66 66 Poor 17(26) 7(11) Unchanged 31(47) 28(42) Good 18(27) 31(47) Long Term 54(82) 49(74) Short Term 12(18) 17(26) Totals 132 24(18) 59(45) 49(37) 103(78) 29(22) Brackets ind i c a t e percentages. The data reveals that patient preference groups do d i f f e r with regard to the RN's perceived patient prognosis. Twenty-seven percent of the low preference group versus forty-seven percent of the high preference patient group were rated as having a "good" prognosis. A reverse standing i s evident when a poor patient prognosis i s perceived: twenty-six percent were low preference patients while only eleven percent are high preference patients. Further t e s t i n g of s t a t i s t i c a l differences between the two groups was not performed. 50 The perceived acuity of patient i l l n e s s also d i f f e r e d between the two patient preference-groups but not to the same degree as the prognosis. RN pa r t i c i p a n t s indicated that eighty-two percent of the low preference patients and seventy-four percent of the high preference patients were i n f l i c t e d with a long term or chronic i l l n e s s . I t i s l i k e l y that s i g n i f i c a n t patient group differences with regards to t h e i r i l l n e s s status does e x i s t , but s i g n i f i c a n c e t e s t i n g was not conducted and t h i s leaves the t h i r d study hypothesis " i n limbo". The number of h o s p i t a l i z e d days f or patients i n each preference group does indi c a t e that there i s a s i g n i f i c a n t difference between the high and low preference groups. Table VIII presents the t - t e s t f i n d i n g s . TABLE VIII PATIENT LENGTH OF HOSPITALIZATION AND THE PREFERENCE GROUP MEMBERSHIP Preference  Group Low High N 40 40 Mean 40.23 23. 28 S.D. 59.98 21.98 F-Value 7.45 2-Tailed  P r o b a b i l i t y 0 . 0 0 0 The length of h o s p i t a l i z a t i o n does seem to be r e l a t e d to the patients' prognosis or t h e i r acuity of i l l n e s s . Low preference patients are those pa-ti e n t s with a long h o s p i t a l i z a t i o n . This coincides with Coser's 1958 theore-t i c a l categorization of the custodial care pattern of h o s p i t a l care f o r patients. Most of these long stay low preference patients seemed to be patients who were i n need of "placement" rather than a "cure" or "therapeutic i n t e r a c t i o n " pattern of care. 51 Patient "Care Needs" C l a s s i f i c a t i o n There i s reasonable homogeneity between the high and low preference patient groups with regards to t h e i r l e v e l of nursing care needs r a t i n g s . More than h a l f of the patients i n each preference group were rated by the Head Nurses at the Level or Type II c l a s s i f i c a t i o n . The proportion of Level or Type III patients was s l i g h t l y d i f f e r e n t f o r the high and low preference patient groups, twelve high preference and eighteen low preference patients. A summary of the findings appears i n the following table. TABLE IX FREQUENCY DISTRIBUTION OF THE CLASSIFICATION OF PATIENT CARE NEED AND PATIENT PREFERENCE GROUP MEMBERSHIP  Patient Needs .;. Preference C l a s s i f i c a t i o n Level Group N I II III IV Totals Low 40 0(0) 22(55) 18(45) 0(0) 40(100) High 40 3(7) 23(58) 12(30) 2(5) 40(100) Totals 80 3(4) 45(56) 30(38) 2(2) Brackets indicate percentages. The t - t e s t f o r group differences i s presented i n the following table. TABLE X PATIENT NEEDS CLASSIFICATION AND PATIENT PREFERENCE GROUP MEMEBERSHIP: T-TEST Preference 2-Tailed df P r o b a b i l i t y Group N Mean S.D. t-Value Low 40 24.98 11.83 1.31 High 40 28.10 9.28 78 0.19 52 Additional data regarding the RN's perception of the emotional needs of each selected patient was c o l l e c t e d . The RN ratings showed that f i f t y - t h r e e percent of the low preference patients were perceived as having "high" emo-t i o n a l needs compared to thirty-two percent of the high preference patients. The "low" emotional need, ratings f o r both patient preference groups was s i m i l a r ; f i f t e e n percent and t h i r t e e n percent. The frequency d i s t r i b u t i o n s appear i n Table XI. TABLE XI FREQUENCY DISTRIBUTION FOR PATIENT PREFERENCE GROUP AND RN PERCEPTIONS OF PATIENTS' EMOTIONAL NEEDS STATUS Preference Emotional Needs Group N : High Moderate Low Low 66 35(53) 21(32) 10(15) High 66 21(32) 36(55) 9(13) Totals 132 56(42) 57(43) 19(15) Brackets indicate percentages. The Head Nurses''overall c l a s s i f i c a t i o n format i s as presented i n Appen-dix D and Table IX was used as a further data source f or the i d e n t i f i c a t i o n of patients' emotional needs status. The Head Nurses' ratings did not d i f f e r f o r the low and high preference patients and were generally quite low f o r both groups; t h i r t y and thirty-two percent r e s p e c t i v e l y . Table XII presents a comparison of the Head Nurse and RN perceptions of patients' emotional needs status. The RNs' "moderate" patient emotional needs ratings were not included i n t h i s analysis.. 53 TABLE XII COMPARISON OF HEAD NURSE AND RN PERCEPTIONS OF PATIENTS' EMOTIONAL NEEDS STATUS Preference Patients' Emotional Needs Status _ Group N . High Need' ~ Low Need" HN RN HN RN HN RN Low 40 66 12(30)* 35(53) 28(70) 10(15) High 40 66 13(32)** 21(32) 27(68) 9(13) Totals 80 132 25(31) • 56(42) 55(69) 19(15) Brackets ind i c a t e percentages. * Moderate emotional needs 21(32) **Moderate emotional needs 36(55) Although the Head Nurses' patient needs c l a s s i f i c a t i o n ratings f o r the selected study patients revealed no differences between the high and low patient preference groups (Chi-Square p r o b a b i l i t y 0.81), the RN ratings do seem to d i f f e r e n t i a t e between the emotional needs status of the two patient groups. The study findings do not reveal any s i g n i f i c a n t differences between the patient preference group and the patients' "care needs" c l a s s i f i c a t i o n , therefore the fourth study hypothesis i s supported: the patients' p h y s i c a l , emotional or teaching care needs did not influence' the RN patient preference r a t i n g s . Adjective Descriptors Rating Scale The findings r e s u l t i n g from the analysis of 132 RN descriptor ratings are presented i n Table XIII. From examination of the mean scores i t can be observed that the High Preference patient group mean ratings were considerably 54 higher than those for- the Low Preference group. It would appear that the RNs found i t e a s i e r to be strongly p o s i t i v e , i . e . to give favourable responses rather than to give a strongly negative r a t i n g f o r a p a t i e n t . This was also a f i n d i n g i n Larson's 1977 study. Thirteen of the seventeen p o s i t i v e l y directed, conforming behaviour descriptors received a mean score greater than three--the highest possible score being four. This also indicates that the conforming behaviour descriptors describe the high preference patient "very w e l l " . For the low preference patient group a l l of thehighest descriptor mean scores were associated with the negatively directed or nonconforming behavioural descriptors. F i f t e e n of the nineteen negative descriptors were within t h i s highest means category but none of the mean scores reached the three point l e v e l . This indicates that the nonconforming behavioural descriptors describe the low preference patient "somewhat or a l i t t l e " . The RN ratings also showed a lower standard deviation of scores f o r the high preference patient group than f o r the low preference group. This f i n d i n g i s p a r t i c u l a r l y i n t e r e s t i n g since the RNs found i t much easier to s e l e c t low preference patients. This does suggest that the RNs have " i n t e r n a l i z e d " t h e i r p rofessional Code of Ethics and p r e f e r to a t t r i b u t e "problem" patient behaviours to patient anxiety. This descriptor received the highest rank for the patients i n the low preference group with a mean of 2.94. Anxiety also had the lowest standard deviation of 0.89. (See Table XIII, p. 54.) In contrast the lowest group means on the Descriptors Rating Scale appears i n Table XIV.(p. 55). I t i s again evident that the RN ratings for the high preference patient presents a more d e f i n i t i v e p i c t u r e . A l l of the low mean scores--given that 1 i s the lowest possible scale s c o r e — r e p r e s e n t non-conforming behavioural descriptors and the majority also have lower standard deviations than those f o r the low preference patients. Seven of the eleven 55-TABLE XIII RANK ORDER DISTRIBUTION OF HIGHEST MEAN SCORES BASED. ON THE ADJECTIVE DESCRIPTORS RATING:SCALE FOR BOTH PATIENT PREFERENCE GROUPS High Preference Low.Preference Descriptor Class* Mean S, .D. Descriptor Class Mean S, .D. Friendly + 3. ,70 0. ,58 Anxious 2.94 0, .89 Appreciative 3. ,67 0, .64 Over Reacts 2.71 1, .12 Cooperative + 3. ,67 0. .51 Chronic Complainer 2.67 1, .03 Sincere + 3. .64 0, .55 Problem Patient 2.65 0 .89 Easy to Attention Please + 3. .59 0, .72 Seeking 2.61 1 .16 Unselfish + 3. ,42 0, .82 Overly Dependent 2.53 1 .15 Considerate + 3. .41 0 .86 Grouchy 2.39 0 .99 Obedient + 3, .38 0 .70 Apathetic 2.36 1 .10 Trusting + 3. .36 0 .78 Manipulative 2.32 1 .18 Interested i n A Nuisance 2.24 0 .90 Getting Well + 3, .36 0 .97 I n t e l l i g e n t + 3, .14 0 .88 Angry 2.12 0 .97 Understanding + 3, .09 1 .11 C h i l d i s h 2.08 0 .93 Good + 3, .03 1 .23 Untidy 2.06 0 .97 Ho s t i l e 2.05 1 .01 Responsible for I l l n e s s 2.00 1 .12 * Class ( +) Conforming Behavioural Descriptors (-) Nonconforming Behavioural Descriptors 56 TABLE XIV RANK ORDER DISTRIBUTION OF LOWEST MEAN SCORES BASED ON THE ADJECTIVE DESCRIPTORS RATING SCALE FOR BOTH PATIENT PREFERENCE GROUPS . High Descriptor Preference Class* Mean S.D. Low Preference Descriptor Class Mean S .D. Manipulative - 1.15 .50 Gossipy - 1.42 1 .01 Complainer - 1.17 .37 Model Patient + 1.44 .68 Gossipy - 1.20 .47 Confused - 1.52 .85 Attention Seeking _ 1.24 .50 Asks too many Questions - 1.64 .97 Overly Dependent _ 1.24 .56 Optimistic + 1.73 .89 H o s t i l e - 1.27 .62 Understanding + 1.73 1 .02 A Nuisance - 1.30 .66 Reliable + 1.77 .76 C h i l d i s h - 1.30 .61 Trusting + 1.89 .88 Problem Patient _ 1.32 .64 Good + 1.92 . 93 Angry - 1.32 .56 Helpful + 1.92 .77 Grouchy - 1.33 .64 Withdrawn - 1.98 .94 Asks too many Questions _ 1.33 .62 Confused - SL.35 .81 Apathetic - 1.38 .74 Over Reacts - 1.41 .74 Withdrawn - 1.49 .69 Responsible for I l l n e s s _ 1.53 . 93 Untidy - 1.62 . 9 7 * Class (+) Conforming Behavioural Descriptors (-) Nonconforming Behavioural Descriptors 57 low means scores f o r the low preference patients represent conforming beha-v i o u r a l descriptors. The low preference patients are not generally described as model patients, o p t i m i s t i c , understanding, r e l i a b l e , t r u s t i n g , good or helpful'. Four of the t h i r t y - s i x descriptors y i e l d e d low mean scores for both pre-f e r e n c e groups: gossipy, confused, asks too many questions and withdrawn. This f i n d i n g suggests that these descriptors do not meaningfully d i f f e r e n t i a t e the two patient preference groups. The differences between the mean descriptor scores f o r the high and low preference patient group i s more c l e a r l y evident i n Table XV.(page 57). It was of some surprise to the in v e s t i g a t o r that the two patient preference groups had the largest mean difference f o r the adjective descriptor "sincere". This was an addition to the Rich and Dent 1962 patient r a t i n g scale. This f i n d i n g i s d i f f i c u l t to explain. Does i t mean that low preference patients are not perceived to be sincere i n t h e i r interpersonal r e l a t i o n s h i p s ? Is the RN's perception of these patients high anxiety p r i m a r i l y a s o c i a l l y accept-able and non-evaluative response whereas the "sincere" d e s c r i p t i o n i s more evaluative? These questions are more f u l l y examined the the subsequent sections. Figure 4 i s a graphic representation of the mean descriptor score ratings f o r each patient preference group. It i s evident that the mean scores f o r the seventeen conforming descriptors are quite d i f f e r e n t f o r the high and low patient preference groups. The o v e r a l l mean f o r the high preference patient group i s 3.33 compared to 1.82 f o r the low preference patient group. The non-conforming behavioural descriptors do not reveal as large a difference. The o v e r a l l mean f o r the high preference patients was 1.41 and 2.23 for the low preference patients. Again i t i s evident that the RN ratings demonstrated a^greater range of scores f o r the high preference patients; from 3.33 to 1.41. 58 TABLE XV MEAN SCORE DIFFERENCES FOR THE ADJECTIVE DESCRIPTORS BETWEEN THE HIGH AND LOW PATIENT PREFERENCE GROUPS Descriptor Mean Group Differences Sincere 1.61 Model Patient 1.55 Easy to Please 1.53 Complainer 1.50 Trusting 1.47 Appreciative 1.44 Unselfi s h 1.40 Friendly 1.38 Attention Seeking 1.37 Undemanding 1.36 Considerate 1.33 Problem Patient 1.33 Helpful 1.31 Over Reacts 1.30 Overly Dependent 1.29 Reliable 1.22 Cooperative 1.21 Manipulative 1.17 Optimistic 1.13 Good 1.11 Grouchy 1.06 Interested i n Getting Well 1.03 Apathetic 0.98 A Nuisance 0.94 Angry 0.80 C h i l d i s h 0.78 Ho s t i l e 0.78 I n t e l l i g e n t 0.72 Anxious 0.55 Withdrawn 0.50 Responsible f o r I l l n e s s 0.47 Untidy 0.44 Asks too many Questions 0.31 Gossipy 0.23 Confused 0.17 The score ranges.for the low preference patients was 2.23 to 1.82. Examination of Table XV and Figure 4 reveals that some descriptors do not strongly d i f f e r e n -t i a t e the preference groups. With the elimination of a l l descriptors with a mean group difference of less than 1.00 point the two groups are d e f i n i t e l y FIGURE 4 Mean Scores ' 3.5 3.0 2.5 2.0 1.5 1.0 GRAPHIC REPRESENTATION OF THE MEAN DESCRIPTOR RATINGS FOR BOTH PATIENT PREFERENCE GROUPS X = 3.33 X = 1.82 X = 2.23 Preference Code Code: 0 = High X = Low on X = 1.41 1 3 4 5 6 7 9 12 13 14 18 20 22 23 26 32 34 | 2 8 10 11 15 16 17 19 21 24 25 27 28 29 30 31 33 35 36 Conforming Descriptors Nonconforming Descriptors Adjective Descriptors 60 more c l e a r l y distinguished. Thirteen descriptors were omitted i n Figure 5, and they include twelve nonconforming descriptors: gossipy, asks too many questions, untidy, responsible f o r i l l n e s s , withdrawn, anxious, h o s t i l e , c h i l d i s h , angry, a nuisance and apathetic, and only one conforming descriptor was o m i t t e d — i n t e l l i g e n t . The changes i n the range differences between the mean scores i s 3.35 to 1.79 f o r the high preference patients and 2.22 to 1.27 for the low preference p a t i e n t s . The RNs' stated reasons f o r r a t i n g patients as low or high preference were a l l described i n behavioural and de s c r i p t i v e terms s i m i l a r to those i d e n t i f i e d on the Adjective Descriptor Rating Scale. Some examples of RN se l e c t i o n reasons included: ' Old patient, needs a l o t of care, s l i g h t l y confused, uncooperative, no i n t e r e s t i n getting w e l l . D i f f i c u l t to approach pati e n t . Patient i s a complainer, very hard to please. Needs quite a b i t of ti-me i n nursing care. C a l l i n g out frequently requesting help f o r minor things. L i t t l e desire to help s e l f . Attention seeking, manipulative, time consuming. E l d e r l y lady who i s in t e r e s t e d only i n her pain 'which i s questionable'. Requests help f o r minor things, u n w i l l i n g to do things f o r h e r s e l f . Very pleasant to work with although he speaks very l i t t l e E nglish. Uncomplaining, pleasant, c h e e r f u l . Undemanding, e a s i l y pleased. Patient i s very f r i e n d l y . Very stimulating, a r t i c u l a t e s w e l l . Helpful and generally appealing. Very good attitude about l i f e . Very good s e l f image. Interesting past l i f e . Stimulating. Able to converse. Has a good outlook on l i f e which i s an important f a c t o r . FIGURE 5 Mean Scores 3.5 3.0 2.5 , 2.0 1.5 1.0 GRAPHIC REPRESENTATION OF THE DESCRIPTOR SCORES FOR THE LARGEST GROUP MEAN DIFFERENCES BETWEEN THE TWO PATIENT PREFERENCE GROUPS X = 3.36 Preference Code : 0 = High X = Low X—X X = 2.22 O — i X = 1.27 1 3 4 5 6 7 9 13 14 18 20 22 23 26 32 34 Conforming Descriptors Adjective Descriptors 2 11 15 16 21 28 35 Nonconforming Descriptors 62 Discriminant Function Analysis of Patient Group Membership The behaviour descriptors ratings do appear to d i f f e r f o r the high and low preference groups. T h i r t y - s i x descriptors were rated and t h e i r mean scores did d i f f e r e n t i a t e well between the two groups. The discriminant function analysis was conducted i n order to i d e n t i f y the most s i g n i f i c a n t descriptors which define patient group membership. The computer program options for discriminant function analysis which were used i n t h i s study are presented i n Appendix G. The stepwise i n c l u s i o n of adjective descriptors i n the discriminant function analysis appears i n Table XVI. Six descriptors were found which account f o r most of the preference TABLE XVI SUMMARY FOR THE INCLUSION OF ADJECTIVE DESCRIPTORS IN THE DISCRIMINANT FUNCTION ANALYSIS Step Descriptor Wilks' Mahal Entered Name '#*•••- Lambda Distance 1 Sincere 9 0.49 0, .00 4.03 0.00 2 Complainer 11 0.31 0. .00 8.61 0.00 3 Model Patient 5 0.29 0. .00 9.59 0.00 4 Over Reacts 21 0.28 0. .00 10.12 0.00 5 C h i l d i s h 25 0.26 0, .00 11.35 0.00 6 Asks too many 27 0.25 0. .00 11.86 0.00 questions Eigenvalue Cononical Wilks' Chi- ^ Corr e l a t i o n Lambda Square 1 ^ n i 3.011 0.866 0.249 176.40 0.000 group differences. The stepwise analysis revealed that the s i g n i f i c a n t de-sc r i p t o r s were: sincere, chronic complainer, model patient, over reacts, c h i l d i s h and asks too many questions. These findings may be confounded by 63 an unknown bias i n the RN descriptor ratings between the conforming and non-conforming behaviour descriptors. Although the f i f t h descriptor, " c h i l d i s h " , and the s i x t h , "asks too many questions", are included i n the discriminant analysis, they also have low mean group differences and low standard deviations. TABLE: :XVII ADJECTIVE DESCRIPTOR RATINGS AND PATIENT GROUP MEMBERSHIP-DISCRIMINANT FUNCTION ANALYSIS RN Descriptor Agreement with Preference ^ The C l a s s i f i c a t i o n of Group — High and Low Preference Ratings Patients Low High Low 66 60(91) 6(9) High 66 2(3) 64(97) The discriminant analysis reveals that s i x of the t h i r t y - s i x descriptors p r e d i c t RN preferences and patient preference group membership. This data i s presented i n Table XV I I . Six of the f o r t y low preference group patients were m i s c l a s s i f i e d based on the RN descriptor ratings while only two of the high preference patients were m i s c l a s s i f i e d . Overall ninety-four percent of the RNs' preference s e l e c t i o n of patients were c o r r e c t l y c l a s s i f i e d according to t h e i r descriptor r a t i n g s . A representation of the findings from the discriminant analysis i s pre-sented i n Figure 6. The eight m i s c l a s s i f i e d patients were p r i m a r i l y the re-su l t of mid-scale RN descriptor r a t i n g s . FIGURE 6 DISRCIMINANT FUNCTION ANALYSIS FOR PATIENT GROUP MEMBERSHIP: CLASSIFICATION OF RN PREFERENCE RATINGS ; AND THE PATIENT BEHAVIOURAL DESCRIPTOR RATINGS 2 0 f — LOf— 0 0 0 0 0 0 o. 0 o' 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 o . 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 - 3 - 2 - 1 . HIGH PREFERENCE • - PATIENTS 0 0 0 0" 0 0 0 0 0 0 0 0 0 OX a o o J M C • 0 °Mx 0 . X. .0 x l x M i s c l a s s i f i e d Patients f x X X X X X X X X ; x : X rX x i x X X X X X X X X X X X X LOW PREFERENCE PATIENTS ON X, X X 65 The s i x low preference patients who were m i s c l a s s i f i e d were described as follows: , 1. Tends to be a behaviour problem. Anxious about outcome so i s i n c l i n e d to be hesitant about new nurses doing hi s treatments. 2. Does not speak.or understand English. 3. Patient i s t a l k i n g constantly and i s loud. Even when you do things for her she doesn'.t stop' t a l k i n g and prevents you from doing your treatments. 4. Is so extremely t a l k a t i v e that a person working i n that room can't get-anything done. 5. Poor prognosis and patient i s aware of t h i s . Family can be very d i f f i c u l t at times. 6. Patient has many c u l t u r a l differences and does not o f f e r the respect most nurses f e e l should be offered to them. Patient's family i s anxious and frequently request assistance—seemingly o b l i v i o u s of other occurrences on the ward. The two high preference m i s c l a s s i f i e d patients were described by the RNs as being: 1. Very heavy patient (350 l b s . ) . D i f f i c u l t to care f o r without assistance. At times i s unpleasant and! uncooperative. 2. Very i l l . Requires good basic care. Usually cooperative. Since only s i x percent of the patients were- m i s c l a s s i f i e d using the behavioural descriptors as independent variables further analysis was not warranted. The discriminant function analysis also computed the regression or c l a s s i f i c a t i o n c o e f f i c i e n t s f or each patient preference group based on the descriptors. This information i s presented i n the following table (page 65). Based on the findings from the patient descriptors, the RN c l a s s i f i c a t i o n of high and low preference patients and the discriminant function analysis i t i s apparent that the f i f t h study hypothesis i s not supported. There i s a strong i n d i c a t i o n that the RNs' c l a s s i f i c a t i o n of high or low preference patients i s p o s i t i v e l y and d i r e c t l y r e l a t e d to t h e i r perceptions regarding conforming or nonconforming patient behaviours. 66 TABLE XVIII REGRESSION COEFFICIENTS BASED ON THE RNS' SELECTED PATIENT GROUP MEMBERSHIP AND THE RNS' PATIENT DESCRIPTOR RATINGS Y Low Preference 3.66X5 + 3.81Xg + 3.20X 11 + 0.12X 21 + 4.51X 25 + 2.03X 9 7 + (-17.97) Y, High Preference 4.88X5 + 7.28Xg + 0.67X n + (-1.76)X 2 1 + 6.25X2£. + 2.99X 2 ? + (-26.60) The nonconforming patient i s least preferred. This fi n d i n g agrees with findings from'.previous studies such as Stockwell, 1972; Gladstone, 1980; Morimoto, 1955; Duff and Hollingshead, 1968; and Blaylock, 1972. The study hypotheses are r e l a t e d to questions of values or attitudes (Rokeach, 1973). The three study purposes r e f e r to the i d e n t i f i c a t i o n of: 1) which patients are. most and least preferred; 2) why i s th i s so; and 3) what difference does RN preference make to the q u a l i t y of nursing care. This section responds to the t h i r d study question. During and a f t e r the data c o l l e c t i o n period the in v e s t i g a t o r f e l t that the q u a l i t y of nursing care differences between the high and low patient preference groups did not e x i s t . Figure 7 and.fTable. XIX represent the q u a l i t y scores f o r both patient preference groups and each nursing u n i t . The Medicus Quality monitoring tool incorporates four major q u a l i t y of care objectives: the planning of care, physical care, psychosocial care and Quality of Nursing Care Scores 67 TABLE XIX DISTRIBUTION OF THE QUALITY OF NURSING CARE SCORES OVER THE FOUR MAJOR OBJECTIVES •'POR EACH NURSING UNIT AND PATIENT PREFERENCE GROUPS Care Preferences ..; High Low A B ' C D A B C D 1.1 ! 22 96 75 57 95 54 38 46 1.2 ! 25 33* 77 31 67 40 33 75 1.3 ! 13 33 33 50* 17 75* 34* 13* 1.4 ! 00 00 05 19 12 34 17 00 1.5 ! 00 38 50 27 00 56 61 50* 1,.0 | 10 35 42 32 40 45 33 29 2.1 ! 80 70 75 74 68 77 69 100 2.2 1 77 87 85 71 75 86 78 87 2.3 ! 67 86 87 70 93 84 86 86 2.4 ! 100* 42 100* 100* 100* 100* 100* 100* 2.5 ! 17 00 00 00 63 30 15 00 2.6 ! 42* 50* 56 19* 58 68 67* 63 2.7 ! 33 00* 50* 00* 33 50* 33 83 2.8 ! 100* 33 67 00* 33 100 100* 33 2.9 | * 100* 00* 100* 25 43 * 17 2.0 ! 63 61 64 59 61 71 67 67 3.1 ! 43 40 13 22 43 38 18 20 3.2 ! 84 84* 75 . 72 63 84 89 92 3.3 • 86 38* 50 42 48 80 75 75 3.4 ! 2 6 20 25 30 52 44 44 64 3.5 !• 45 00 50 33 25 33 30 50 3.6 | 00 00* 17 30 50 24 20 50 3.7 i i 3.0 j 43 27 32 33 47 ' 49 40 53 4.1 ! 4 5 30 48 13 35 26 33 75* 4.2 ; 00* 10* 40 50* 37* 00 17- 39 4.0 ! 3 2 24 46 25 36 17 26 57 * Means i n s u f f i c i e n t v a l i d responses f o r a r e l i a b l e score. FIGURE 7 DISTRIBUTION OF THE QUALITY OF NURSING CARE SCORES OVER THE FOUR MAJOR QUALITY OBJECTIVES FOR EACH NURSING UNIT AND PATIENT PREFERENCE GROUP 80 60 4 0 20 UNIT PREFERENCE OBJECTIVE PLANNING OF CARE — / / / III NNN ll/lNlTk I/N/NN 11111 Nik lifuliii I IN INN _ l/N/NN lll/NNJII \l1111111111 I IN III IIII IIl\ N/\ l//\/ll, I NJ III 11,-. IINNINN II Nil III II NNIIINN IINNINN IINNINN NNIIINN lill!Ililll NNIIINN A B C D A B C D LOW- HIGH PHYSICAL CARE //-/<-• 7 7 / NkllNNII II III INI l\ ni 111-1 ilr-ii i.i IUI ii • iiiiiiiiii in in mi /////I/rn IIIIIIIIII IIIIIIIIII IIIIIIIIII MINI I IN I IINIirill 1111111111 tl/ININN ihii'iriu xiniNiiii INININI XlNlNlIN -r-Nk 71 NUN Nil Nil IINNINN NUN INN ////Ill/Ill II INI I III I III i min i IIIIIIIIII!! mimim mn ni II 11 in nm m: i nnnuni IN NUN IN III INI NIL III III IIIIL I III III INI III III III III INI I INI II IIII III INI, llllllllllli A B C D LOW ,A B C D HIGH II PSYCHOSOCIAL CARE /-/-II II N //' III I III III IN IIIIIIIIII IIIIIIIIII IIIIIIIIII IIIIIIIIII IIIIIIIIII IIIIIIIIII IIIIIIIIII mn jj in INN III INN III NllhhhNN NNIIINN II INI lllll I INI INI II I III INI III IINNINN I INI I INI I I INI II lllll NNIIINN II INI I III I IINNINN NNIIINN A- iB C D A )B C D LOW H'IGH I I I EVALUATION. OF CARE III III III /// // /// //• /// III IIIIIIII iik mi ii ii iik IIIiIIII nimnm IIIIIIIIII! IINNINN i ii II nun NI IN IN III III NI III 111 UN III III III ill! I 111 111 •111111 •mill II ml IIII Nil Nil 11III 111 II11 IIIIIIIIIIII Nil INI Nil llllllllllli •rA \B D D LOW A L B :c D H'IGH ON 00. IVv 69 the evaluation of care. From Figure 7 i t i s obvious that the highest q u a l i t y of care scores were those associated with the second objective - Physical Care. The o v e r a l l unit mean scores varied very l i t t l e with the range of scores f a l l i n g between 59 and 71. The mean score f o r the high preference patient group f o r objective II was 66.50. The low preference patient group had a mean score of 61.75 for the same phys i c a l care objective. The standard deviations for both of the patient preference groups i s also comparatively low with values of 2.22 f o r the low preference patient group and 4.12 f o r the high preference patient group. The mean q u a l i t y scores for the remaining three objectives are much lower than those f o r the physical care objective and these are outlined i n Table XX. TABLE XX MEAN SCORES AND STANDARD DEVIATIONS OF THE QUALITY OF NURSING CARE SCORES OVER THE FOUR OBJECTIVES AND BETWEEN BOTH PATIENT PREFERENCE GROUPS Preference Quality of Nursing Care Group Quality  Objective Mean S.D. Low I II III IV 29.75 61.75 33.75 31.75 13.82 2.22 6.70 10.15 High I II III IV 36.75 66.50 47.25 34.00 7.14 4.12 5.44 17.19 70 FIGURE 8 QUALITY OF NURSING CARE "OBJECTIVE" SCORES FOR THE HIGH AND LOW PREFERENCE PATIENT GROUPS High = 0 "I II J I H IV.v ; ' •• Objectives -The t h i r d q u a l i t y objective--physical care--has the next lowest standard deviation of scores with 6.70 and 5.44. This i s also the only objective that reveals a considerable difference i n the mean scores f o r the high and low patient preference groups. Figure 8 displays these findings. The o v e r a l l q u a l i t y score means f o r the two patient preference groups do reveal some d i f -ferences . The scores over the four objectives show that the low preference patient group has a mean score of 39.25 while the high preference patient group has a mean q u a l i t y score of 46.13. The between group differences and t h e i r mean scores i s more s i g n i f i c a n t when the standard deviations are con-sidered. There was e s s e n t i a l l y no within group difference between the patient 71 preference groups and th i s i s indicated by standard deviations of 15.83 and 15.88 f o r each of the patient preference groups. A two-way analysis of variance, with preference group and q u a l i t y objectives as the independent variables revealed s i g n i f i c a n t differences between the two patient preference groups ..and also among the four q u a l i t y objective scores. These findings are presented i n Table XXI. Source TABLE XXI TWO-WAY ANALYSIS OF VARIANCE FOR PATIENT PREFERENCE GROUP AND THE QUALITY OF NURSING CARE df Preference Group 1 Quality Scores 3 Pref X Quality 3 Error 24 Mean Square 378.13 1732.54 46.54 92.06 F-Value 4.11 18.82 0.51 P r o b a b i l i t y 0.0515 0.0000 0.69 From the analysis i t i s apparent that there are s i g n i f i c a n t differences among the q u a l i t y scores for the four objectives. The physical care objective (II) i s s i g n i f i c a n t l y higher f o r both patient preference groups than are the scores f o r objectives I, III and IV. The s i g n i f i c a n c e of the patient preference group differences i s a l i t t l e more problematic. The 0.0515 cal c u l a t e d p r o b a b i l i t y s t a t i s t i c comes so close to the 0.05 c r i t i c a l value that was chosen f o r the r e j e c t i o n of study hypotheses that the in v e s t i g a t o r i s l e f t with a decision. Patient pre-ference group membership does seem to influence the reported q u a l i t y of nursing care. For t h i s study the in v e s t i g a t o r considers the 0.515 pro-72 b a b i l i t y gives s u f f i c i e n t support to r e j e c t the s i x t h study hypothesis. Since the mean score differences f o r patient preference group membership and the q u a l i t y of nursing care, s p e c i f i c a l l y i n the-psychosocial category--Objective #3--were r e l a t i v e l y large, as seen i n Figure 8, a one-way analysis of variance was performed. Table XXII presents the fi n d i n g s . TABLE XXII ONE-WAY ANALYSIS OF VARIANCE FOR PATIENT PREFERENCE GROUP AND THE QUALITY OF NURSING CARE SCORES AMONG THE FOUR OBJECTIVES Source df Mean Square F-Value P r o b a b i l i t y Quality Score Objective I 1 98.00 0.81 0.41 II 1 45.13 4.12 0.09 III ' 1 364.50 9.79 0.02 IV 1 10.13 0.05 0.81 Only the t h i r d q u a l i t y objective--psychosocial care--shows s i g n i f i c a n t differences between the high and low patient preference group. This f i n d i n g can be viewed as adding support to the relevance of the nurse-patient i n t e r -action aspects arid the q u a l i t y of nursing care. Much of the l i t e r a t u r e and many of the nursing studies have focused on the nurse-patient i n t e r a c t i o n patterns as a prime f a c t o r i n the evaluation of the q u a l i t y of nursing care (Duff and Hollingshead, 1968; Morimoto, 1955; Coser, 1958; Wandelt, 1970; Lorber, 1975; Leonard, 1966; and Davis, 1968). 73 As was mentioned i n an e a r l i e r section the researcher had estimated that the q u a l i t y of nursing care would be found to be much the same for the high preference and low preference patient groups. The o v e r a l l scores i n t h i s study were comparatively lower than those which have been reported i n other studies which have used the Medicus Quality monitoring tool (Jelinek, Haussmann, e t v a l . , 1972; and Haussmann, Hegyvary and Newman, 1976). In the i n t e r - r a t e r r e l i a b i l i t y t e s t i n g the l a t t e r authors reported that the education of the observer did influence t h e i r r a t i n g s . In general q u a l i t y scores were in v e r s e l y r e l a t e d to education: as education l e v e l i n -creased the q u a l i t y scores decreased. \ Since the i n v e s t i g a t o r f e l t some concern that the study findings could be due to a measurement a r t i f a c t , an ex-post-facto analysis of the Medicus Quality Monitoring tool was undertaken. The measurement instrument uses seven sources i n the computation of a summary score of the q u a l i t y of nursing care. These sources include: the patient record, patient observation, patient interview, RN interview, RN observation and observer influence. From the 154 c r i t e r i a used i n t h i s study a d i s t r i b u t i o n according to the information source i s presented i n Table XXIII (page 73). -From t h i s d i s t r i b u t i o n table i t can be seen that most of the c r i t e r i a r e f e r to information that i s from the patient record (36%). Some ninety percent of the items ( c r i t e r i a ) which contribute to the q u a l i t y score for the f i r s t Objective: The Plan of Nursing Care i s Formulated are a r r i v e d at from a review of the patient's records. The information sources are more evenly divided for the q u a l i t y score f o r Objective I I : Physical Care Needs. Twenty percent of the responses are derived from a review of the patient record; t h i r t y - e i g h t percent from observation of the patient and his/her environment, and twenty-five percent from the patient interview. For t h i s study the t h i r d TABLE XXIII DISTRIBUTION OF THE MEDICUS QUALITY OF NURSING CARE CRITERIA FOR THE FOUR OBJECTIVES AND THE INFORMATION SOURCE Quality Patient S o u r c e o f I n f o r m a t i o n Objective Records Observation Interview Patient Observer Totals Patient RN Patient RN Environment Inference i :- - ; Plan of Nursing Care 29(90)' 0 0 0 2 0 1 32 (21) II Physical Care Needs 13(20 12(18) 2 17(25) 7(11) 13(20) 2 66 (43) ITT Psychosocial Care Needs 4(9) 0 '3 33(77) •5(11) 0 1 46 (30) IV Evaluation of Care 10 0 0 0 0 0 0 10 C6) Totals 56(36) 12(8) 5(3): 50C32) 14(9) 13(8) 4(3) 154* * Although the Medicus methodology includes some 250 c r i t e r i a and 25 separate worksheets, only nine d i f f e r e n t worksheets were used i n th i s study because there were few study patients i n the Level I or Level IV c l a s s i f i c a t i o n . J 75 Objective: Psychosocial Needs i s most i n t e r e s t i n g since i t was t h i s Objective that revealed s i g n i f i c a n t differences i n the q u a l i t y scores between the high and low patient preference groups. Nearly a H (77%) of the q u a l i t y rating's f o r t h i s Objective r e l y on the patient interview. Given the perceived beha-v i o u r a l differences between the two patient study groups t h i s may confound the q u a l i t y scores with the general "outspokenness" of the low preference patient group. A d i f f e r e n t d i s t r i b u t i o n of the information sources i n the Medicus Quality Scale would have considerably strengthened the v a l i d i t y of t h i s study's q u a l i t y of care f i n d i n g s . This chapter has presented the findings of the research. The l a s t chapter w i l l summarize the purpose and procedures as well as the f i n d i n g s , and discuss the conclusions and implications. 76 CHAPTER VII SUMMARY, CONCLUSIONS AND IMPLICATIONS Summary of Purposes and Procedure This study was undertaken i n order to compare the q u a l i t y of nursing care between two patient groups. The purposes were: 1) to i d e n t i f y which patients the RNs would most and least prefer to give care; 2) what were the perceived behavioural c h a r a c t e r i s t i c s of these patients; and 3) whether t h i s RN care preference influenced the q u a l i t y of nursing care received by e i t h e r preference group. Much of the data was c o l l e c t e d by means of r a t i n g scales administered personally to t h i r t y - t h r e e RNs responsible f o r the care of the selected study patients. The RN p a r t i c i p a n t s chose the most and l e a s t preferred patients, according to what they'perceived as the majority view of nurses on t h e i r nursing unit at the time of the study. These RNs also responded to questions r e l a t e d to each of the patients' socio-economic status, i l l n e s s and needs c l a s s i f i c a t i o n . An RN r a t i n g of patient behaviours was also e l i c i t e d . Included i n t h i s scale were seventeen conforming sick r o l e be-haviours and nineteen deviant or nonconforming sick r o l e behaviours. Each nurse was i n s t r u c t e d to ind i c a t e whether the descriptor described the selected 77 patient on a four point scale of "very w e l l " , to "not at a l l " . The f i r s t part of the data analysis focused on the demographic, socio-economic, i l l n e s s status and needs c l a s s i f i c a t i o n (for both patient groups. A second part of the study examined RN responses to each of the behavioural descriptors to determine whether patient preference s e l e c t i o n was r e l a t e d to conforming or nonconforming patient behaviours. A discriminant function analysis was conducted i n order to determine the degree of agreement between patient preference and the ascribed conformity of sick r o l e patient behaviours. The t h i r d part of the study incorporated an analysis of the q u a l i t y of nursing care scores f o r each patient preference group. Summary of Findings  C h a r a c t e r i s t i c s of the RN Sample The nurses were d i v e r s i f i e d with respect to age, nursing education and length of employment i n nursing. Seventeen of the nurses had less than one year experience and 55% were under twenty-five years of age. There were 8 h o s p i t a l diploma graduates, 8 baccalaureate and 17 college degree graduates. C h a r a c t e r i s t i c s of the Patient Sample  Hypothesis I For t h i s study the patient ages and sex were considered as demographic va r i a b l e s . The two patient preference groups were very homogeneous with respect to these two v a r i a b l e s . Nearly one-half of the patients i n the high preference and low preference patient groups were males and over s i x t y -four years of age. S t a t i s t i c a l tests revealed that there were no s i g n i f i c a n t 78 differences between the two patient preference groups and therefore the f i r s t n u l l hypothesis was accepted. Hypothesis II The education, occupation, patient class status and r e l i g i o n represented the socio-economic v a r i a b l e s . The RN p a r t i c i p a n t s were unable to state the education or occupation f o r eighty-eight percent of the 132 ra t i n g s . The findings f o r the low and high patient preference group were so s i m i l a r that the n u l l hypothesis was not tested. The majority of patients i n each preference group were estimated by the RNs to be.middle class and t h e i r r e l i g i o u s f a i t h s were s i m i l a r l y d i s t r i b u t e d f o r each preference group with the Protestant f a i t h accounting f o r one-half of the patients i n each group. The groups' socio-economic s i m i l a r i t y did not warrant further t e s t i n g of the n u l l hypothesis and the second hypothesis was accepted. Hypothesis III 1. From the nurses' perceptions of the i l l n e s s status of the selected study patients some differences between the high and low preference groups were'apparent. One quarter of the RN ratings indicated that the prognosis f o r the low preference patients was poor or that the patient's health status would deteriorate. This i s i n contrast to the estimated prognosis for those patients i n the high preference group where one-half of the ratings indicated a good patient prognosis or an improved health status. 2. The nurses also reported differences i n the expected duration of i l l n e s s f o r each patient preference group. Eighty-two percent of the low pre-79 ference patient ratings indicated that the patients' i l l n e s s was chronic compared to seventy-four percent f o r the high preference p a t i e n t s . 3. The number of h o s p i t a l i z e d days was also d i f f e r e n t f o r each patient group. The high preference patients had a mean of twenty-three hospi-t a l i z e d days and the low preference patients had been h o s p i t a l i z e d f o r an average of f o r t y days. The n u l l hypothesis was tested by the t - t e s t and s i g n i f i c a n t group differences were reported, "therefore, Hypothesis III was rejected. Hypothesis IV A standardized patient c l a s s i f i c a t i o n t o o l revealed that the patient groups did not d i f f e r with regard to t h e i r nursing care needs. More than one-half of the patients i n each group were c l a s s i f i e d as Level I I . The t - t e s t found no s i g n i f i c a n t group differences and Hypothesis IV was accepted. A further analysis was conducted to i d e n t i f y whether the two preference group patients were perceived as having d i f f e r e n t emotional care needs. The RN participants'.responses revealed that 53% of the low preference patients were perceived as having high emotional needs compared to 32% of the high preference patients. The standardized c l a s s i f i c a t i o n tool which was completed by the Head Nurse or her delegate ind i c a t e d that the emotional need status f o r each patient preference group was about t h i r t y percent f o r both the high and the low preference patients. Responses to the Adjective Descriptor Rating Scale  Hypothesis V The sick r o l e conforming behavioural descriptors were strongly r e l a t e d to the RN s e l e c t i o n of high preference patients while the sick r o l e deviant behavioural descriptors correlated with the low preference patients. Ninety-80 four percent of the patients c l a s s i f i e d as high or low preference by the RNs were s i m i l a r l y c l a s s i f i e d by use of the descriptors as the dependent variable i n a discriminant function analysis. Six behavioural descriptors were suf-f i c i e n t to account for the RNs' s e l e c t i o n of patient preference group mem-bership. These descriptors were: sincere, chronic complainer, model patient, over reacts, c h i l d i s h , and asks too many questions. Based on these findings, the f i f t h study hypothesis was rejected. Quality of Nursing Care Scores  Hypothesis VI The q u a l i t y of nursing care scores between the two patient preference groups were s i g n i f i c a n t l y d i f f e r e n t (p = .05) or "nearly s i g n i f i c a n t " (p = .0515). The score f o r the physical care objective was s i g n i f i c a n t l y higher for both patient groups than were the scores f o r the three remaining objectives--care plan, psychosocial needs and evaluation of care. For one of these four q u a l i t y of nursing care objectives there was a d e f i n i t e difference between the high and low preference patient groups. The psychosocial needs category received a s i g n i f i c a n t l y lower q u a l i t y score for the low preference patient group. The s i x t h study hypothesis as tested by both the patient preference group and q u a l i t y objective scores was therefore rejected. The study findings revealed that the RN care preferences were influenced by the patients' i l l n e s s status and the perceived patient sick r o l e behaviours. 81 The q u a l i t y of nursing care i s , i n turn, influenced by the RNs' care pre-ference and the differences i n the behavioural descriptions f o r each patient preference group. Conclusions 1. The extent and meaningfulness of RN Care Preferences has been 1 . underestimated. That RNs p r e f e r to give care to some patients more than to others i s not s u r p r i s i n g . In fa c t i t i s supported i n findings reported by many other wri t e r s . Gladstone and McKegney reported that the favored patients were described as cooperative, calm, happy and smiling, while the least favored patients were manipulative, dependent, uncooperative and depressed (Gladstone and McKegney, 1980). S i m i l a r descriptions of the most and least preferred patients were found i n the studies by Rich and Dent, 1962; Larson,.1977; Blaylock, 1972; and Rickelman, 1972. Understandably, neither the American nor Canadian Codes of Ethics f or nurses acknowledge that nurses are- also persons with d i f f e r e n t values and preferences. '. The nurses' i n d i v i d u a l needs, i n t e r e s t s and values are as heterogeneous as those of t h e i r patients and only an open and honest disclosure of t h e i r preferences w i l l promote action. The denial or avoidance of the RN preference issue only exacerbates a p o t e n t i a l l y non-therapeutic nurse-patient i n t e r a c t i o n pattern. Janken addresses t h i s RN non-preference f o r problem patients. She believes that a non disclosure of problems with patients creates a "nurse i n c r i s i s " s i t u a t i o n (Janken, 1974) . The writings of Gunther, 1979, and Zahourek and Morrison, 1974, o f f e r a d d i t i o n a l support f o r the meaningfulness 82 of open communications—nurse-nurse, nurse-patient and nurse-others. Because the RN has a r e l a t i v e l y constant demand to be i n contact with her patients the Mental Health Nurse consultant has ;a r e s p o n s i b i l i t y to help the RN understand her reactions i n order to promote a self-awareness and enhance the nursing care received by patients (Grace, 1974 and Peterson, 1969). An expressed caring about the feelings of nurses may be transferred to a caring about patients' f e e l i n g s . The l e a s t preferred patients could o f f e r the self-aware nurse with a challenge rather than a f r u s t r a t i o n . 2. RN s e l e c t i o n of the least preferred patient i s most strongly r e l a t e d to a t t r i b u t e d nonconforming or deviant patient behaviours. A l l but three of the t h i r t y - s i x patient behavioural descriptors indicated s i g n i f i c a n t group differences between the high and low patient preference group. These three descriptors were: Number 27--asks too many questions (p = 0.099); Number 30--largely responsible f o r present i l l n e s s (p = 0.060); and Number 36--confused (p = 0.118). It i s unclear why descriptor number 27 showed non- s i g n i f i c a n t group differences and was selected as a s i g n i f i c a n t variable i n the discriminant function analysis. Only two of the low preference patients were selected because they did not speak or understand English. A s i m i l a r number of high preference and low preference patients belonged to minority r e l i g i o u s f a i t h s . This information indicates that c u l t u r a l and r e l i g i o u s differences, per se, do not account f o r the RNs' s e l e c t i o n of high or low preference patients. The data analysis also revealed that the RN p a r t i c i p a n t s had a very l i m i t e d knowledge of the s o c i a l and economic status of t h e i r p a t i e n t s -regardless of whether the patient was most preferred or l e a s t preferred. 83 It i s d i f f i c u l t to f i n d any evidence that the Morimoto conclusions are sup-ported i n t h i s study (Morimoto, 1955). Few patients i n e i t h e r preference group were known as 'persons' by the RN p a r t i c i p a n t s and i n d i v i d u a l i z e d patient care i s not l i k e l y when knowledge of the patient's socio-economic status i s so l i m i t e d . This data also brings into question Larson's 1977 findings that RNs did a t t r i b u t e more negative or nonconforming behaviours to patients i n the lower socio-economic category. Since her study used an experimental design with hypothetical patients t h i s laboratory s e t t i n g approach may indeed stimulate responses that d i f f e r from those found i n the f i e l d . In another study Lorber, 1975, found that the age and education of the patients were the best predictors of conforming or deviant patient behaviours. In contrast, t h i s present study found that patient age did not p r e d i c t pre-ference group membership and educational status was only data i n f e r r e d by the RN so i t was not s t a t i s t i c a l l y tested. The Smith and Apfeldorf, 1965, study reported a high c o r r e l a t i o n between the a t t i t u d e of patients toward h o s p i t a l s and t h e i r behaviours during hos-p i t a l i z a t i o n . P o s i t i v e attitudes were r e l a t e d to conforming patient be-haviours . 3. The i n s t i t u t i o n a l i z e d expectations of patient sick r o l e behaviours  have been " i n t e r n a l i z e d " by nurses. The behavioural expectations of the sick r o l e p o s s i b l y predate Parsons ' 1951 t h e o r e t i c a l analysis but h i s t h i r t y year o l d theory i s s t i l l r e f e r r e d to i n most studies of sick r o l e behaviour. The dependence, cooperation and p a s s i v i t y of the patient that are presumed i n Parsons' t h e o r e t i c a l formulation of the sick r o l e have been questioned mainly by s o c i o l o g i s t s . The education of nurses includes considerable reference to the bio-psycho-84 s o c i a l nature of health and i l l n e s s but i t also excludes d i r e c t mention of sick r o l e expectations. The i n s t i t u t i o n a l i z e d sick r o l e expectations do seem to exert an influence on the RNs' perception of t h e i r most and l e a s t preferred patients. To paraphrase Freidson (1970), the (physician's) attitude towards patients i s l a r g e l y a reactive response and r e l a t e d to the c h a r a c t e r i s t i c s of the prac-t i c e s e t t i n g rather than to the educational influence. The RNs' s e l e c t i o n of t h e i r most preferred patients was indeed congruent with the c l a s s i c a l behavioural expectations of the patient sick r o l e . Con-forming patient behaviours are most preferred and nonconforming or deviant sick r o l e behaviours are l e a s t preferred. The professional-bureaucratic dilemma has been extensively reviewed. This researcher tends to agree with Corwin's conclusions that both p r o f e s s i o n a l -ism and bureaucratization c o n f l i c t with the personalized care that patients require and desire (Corwin, 1960) . The Parsonian professional a t t r i b u t e s of a c o l l e c t i v i t y value o r i e n t a t i o n , an a f f e c t i v e n e u t r a l i t y and a functional s p e c i f i c i t y are quite "non-real". In the h o s p i t a l s e t t i n g i t i s the physicians who eierve as the 'reference group' for nurses (Davis, 1968). The physician's focus on cure i s l a r g e l y modelled by nurses and 'custodial' or 'care' patients are the l e a s t preferred i (Coser, 1958). In an acute h o s p i t a l s e t t i n g the lack of a care o r i e n t a t i o n i s often passed o f f as hotel-needs rather than patient nursing care needs. 85 4. The i l l n e s s status of the patient does influence the RNs' s e l e c t i o n  of low and high preference p a t i e n t s . A s i g n i f i c a n t number of low preference patients had been h o s p i t a l i z e d f o r a greater number of days than those patients i n the high preference group. Although t h i s study did not attempt to asce r t a i n whether the lengthy stays were 'placement' rather than i l l n e s s r e l a t e d other data did reveal that more low preference patients were perceived as having a long term i l l n e s s and a poor prognosis. Many writers have suggested that the Parsonian sick r o l e model i s not applicable to patients with a chronic i l l n e s s (Gallagher, 1976; Twaddle, 1973; Scheff, 1965; Freidson, 1965; and Gordon, 1966). The general p r e s c r i p t i v e or normative theory of Parsons may apply to patients with a l i f e - t h r e a t e n i n g acute i l l n e s s but a l l of the aforementioned authors support a more active r o l e f o r the patient i n t h e i r h e a l t h / i l l n e s s care management. The p a r t i c i p a t i o n of the patient i n choosing the goals and means i s e s s e n t i a l . Long stay pa-ti e n t s have a greater opportunity to learn about the system expectations and sanctions. This knowledge may enhance t h e i r sense of personal control of the environment and patient 'demands' f o r active p a r t i c i p a t i o n may be i n t e r -preted by the nurse as non-compliance or sick r o l e deviance. Many RNs, l i k e physicians, p r e f e r to cure patients rather than to 'simply' care f o r them. A much larger number of the low preference patients were rated as having a poor prognosis. RN a c t i v i t y on behalf of the long term patient was more 'caretaking than healing' (Alfano, 1971), and not as pro-f e s s i o n a l l y rewarding. This statement i s also supported by the r e c r u i t i n g d i f f i c u l t y that i s experienced by long-term care h o s p i t a l s . 86 5. The q u a l i t y of nursing care received by the l e a s t preferred patients i s lower than the care received by the most preferred p a t i e n t s . Although only the psychosocial needs category or the t h i r d objective i n the Medicus Quality of Care Scale indicated that the preference group d i f -ferences were s t a t i s t i c a l l y s i g n i f i c a n t (p = 0.02), the importance of this care dimension has been found to be very low i n a random sample of patients (White, 1972). This difference i n patient importance ratings for psycho-s o c i a l care i s most probably due to the differences i n sampling techniques, i . e . , random versus purposive. A l l of the mean q u a l i t y scores for the other three objectives were lower for the least preferred patient group. The highest q u a l i t y score r a t i n g was f o r the p h y s i c a l care objective with respective group means of sixty-two and sixty-seven. The planning and evaluation of care, Objectives I and IV, were scored much lower. The average scores were t h i r t y and thirty-two for the low preference group and the high preference patient group had average scores of thirty-seven and t h i r t y - f o u r f o r these two objectives. The Medicus scores for the f i r s t and fourth objectives are almost e n t i r e l y based on information from the patient record--twenty-nine of the thirty-two c r i t e r i a or items f o r Objective I and ten of the ten c r i t e r i a f o r the fourth objective. These findings can be p a r t i a l l y explained by the " s t a t e " of nursing prac-t i c e within the sampled nursing u n i t s . None of the nursing units i n the study sample had implemented the 'nursing process' nor had they developed nursing care standards. The nurse-patient assignment methods were b a s i c a l l y a mix of team and functional nursing. The q u a l i t y of nursing care as measured by any current instrument focuses on the written records to determine whether assessment, plan-87 ning and evaluation of patient care i s a p r a c t i c e r e a l i t y . I t i s not s u r p r i s i n g that the patient " s a t i s f a c t i o n " with the q u a l i t y of nursing care was lower f o r the patients i n the low preference group. Although patient s a t i s f a c t i o n with care i s an important q u a l i t y dimension, an instrument which .includes patient-nurse observation and a record review would give a more v a l i d measure of the q u a l i t y of nursing care. Implications Between the idea And the r e a l i t y Between the notion And the act F a l l s the Shadow. T.S. E l i o t The Hollow Men Regardless of whether RN care preferences are values or attitudes they do seem to have a behavioural component. Nursing educators do share some of the r e s p o n s i b i l i t y f o r the nurse p r a c t i t i o n e r s ' a t t i t u d e s . A nursing i n s t r u c t o r ' s emphasis on values c l a r i f i c a t i o n (Uustal, 1978) throughout the students' c l i n i c a l experience could enhance the nurses' self-awareness and reduce the q u a l i t y of care d i f -ferences between the high and low preference patients. Educational programs which respond to t h i s value judgement dilemma i n nursing care have been docu-mented by Nass and Skipper (1971). The psychological aspects of the nurse-patient r e l a t i o n s h i p have been examined by Mathews, 1962; Aiken, 1973, and many others. From the study / 88 findings i t seems that the i n t e r a c t i o n dimension i s a most s i g n i f i c a n t aspect i n the monitoring of the q u a l i t y of nursing care. The f i r s t research p r i o r i t y (Lindeman, 1975) was concerned with the i d e n t i f i c a t i o n of v a l i d and r e l i a b l e i n d i c a t o r s of the q u a l i t y of nursing care. Further study i s needed i n order to determine the e f f e c t of nurses' patient care preferences on the q u a l i t y of nursing care. The measure of the q u a l i t y of nursing care (Medicus) has some v a l i d i t y problems i n a study of t h i s kind. The d i s t r i b u t i o n of the 'source of informa-t i o n ' f o r the q u a l i t y scores i s most varied and t h i s may influence the q u a l i t y scores. Although the discriminant function analysis revealed the meaningfulness of the patient behavioural descriptors as predictors of nurses'.care pre-ferences, d i f f e r e n t s t a t i s t i c a l techniques, such as path analysis, or a regres-sion analysis, may represent a more integrated approach. The tr a c e r methodology (Kessner, 1973) seems most appropriate to t h i s type of nursing research and the u t i l i z a t i o n of nursing diagnoses rather than medical diagnoses may reveal s i g n i f i c a n t r e l a t i o n s h i p s between 'process and outcome' studies of the q u a l i t y of nursing care (Block, 1975). Is i t possible that the "'Bad Patient' Gets Better Quicker" (Glogow, 1973) or i s i t a l l simply an issue of d e f i n i t i o n ? ; not a l l types of conformity with sick r o l e expectations and standards can be c a l l e d 'healthy' nor can a l l types or modes of deviation from such conformity be considered as ' i l l n e s s ' or deviance. The 'problem patients' may be the patient group which o f f e r s the most challenge to the nursing profession i n the consolidation of p r a c t i c e philosophy and values. 89 BIBLIOGRAPHY Aiken, L. and J'.L. 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Zimmer, M.J., "Quality Assurance f o r Nursing Care", Proceedings of an In s t i t u t e  J o i n t l y Sponsored by the American Nurses Association and the National  League of Nursing, 1973. 95 APPENDIX A AMERICAN NURSES ASSOCIATION-CODE OF ETHICS The nurse provides services with respect for human d i g n i t y and the uniqueness of the c l i e n t u n r e s t r i c t e d by considerations of s o c i a l or economic status, personal a t t r i b u t e s , or the nature of health problems. The nurse safeguards the c l i e n t ' s r i g h t to privacy by j u d i c i o u s l y protect-ing information of a c o n f i d e n t i a l nature. The nurse acts to safeguard the c l i e n t and the pu b l i c when health care and safety are affe c t e d by the incompetent, unethical, or i l l e g a l prac-t i c e of any person. The nurse assumes r e s p o n s i b i l i t y and a c c o u n t a b i l i t y f o r i n d i v i d u a l nursing judgements and actions. The nurse maintains competence i n nursing. The nurse exercises informed judgement and uses i n d i v i d u a l competence and q u a l i f i c a t i o n s as c r i t e r i a i n seeking consultation, accepting respon-s i b i l i t i e s , and delegating nursing a c t i v i t i e s to others. The nurse p a r t i c i p a t e s i n a c t i v i t i e s that contribute to the ongoing development of the profession's body of knowledge. The nurse p a r t i c i p a t e s i n the profession's e f f o r t s to implement and improve standards of nursing. The nurse p a r t i c i p a t e s i n the profession's e f f o r t s to e s t a b l i s h and main-t a i n conditions of employment conducive to high q u a l i t y of nursing care. The nurse p a r t i c i p a t e s i n the profession's e f f o r t to protect the pu b l i c from misinformation and misrepresentation and to maintain the i n t e g r i t y 96 of nursing. 11. The nurse collaborates with members of the health professions and other c i t i z e n s i n the promoting community and national e f f o r t s to meet the health needs of the p u b l i c . 97 APPENDIX B CANADIAN NURSES ASSOCIATION CODE OF ETHICS  General P r i n c i p l e s 1. The human person, regardless of race, creed, colour, s o c i a l class or health status, i s of i n c a l c u l a b l e worth, and commands reverence and respect. 2. Human l i f e has a sacred and even mysterious character and i t s worth i s determined not merely by u t i l i t a r i a n concerns. 3. Caring, the central and fundamental focus of nursing, i s the basis for nursing e t h i c s . I t i s expressed i n compassion, competence, conscience, confidence and commitment. I t q u a l i f i e s a l l the r e l a t i o n s h i p s i n nursing p r a c t i c e , education, administration and research including those between nurse-client; nurse-nurse; nurse-other helping p r o f e s s i o n a l s ; educator-colleague; faculty-student; researcher-subject. Statements of E t h i c a l R e s p o n s i b i l i t y 1. Caring demands the p r o v i s i o n of helping services that are appropriate to the needs of the c l i e n t and s i g n i f i c a n t others. 2. Caring recognizes the c l i e n t ' s membership i n a family and a community, and provides f o r the p a r t i c i p a t i o n of s i g n i f i c a n t others i n h i s or her care. 3. Caring acknowledges the r e a l i t y of death i n the l i f e of every person, and demands that appropriate support be provided f o r the dying person and family to enable them to prepare f o r , and to cope with death when i t i s i n e v i t a b l e . 98 Caring acknowledges that the human person has the capacity to face up to health needs and problems i n h i s or her own unique way, and d i r e c t s nursing action i n a manner that w i l l a s s i s t the c l i e n t to develop, main-t a i n or gain personal autonomy, s e l f - r e s p e c t and self-determination. Caring, as a response to a health need, requires the consent and the p a r t i c i p a t i o n of the person who i s experiencing that need. Caring dictates that the c l i e n t and s i g n i f i c a n t others have the knowledge and information adequate for free and informed decisions concerning care requirements, a l t e r n a t i v e s and preferences. Caring demands that the needs of the c l i e n t supersede those of the nurse, and that the nurse must not compromise the i n t e g r i t y of the c l i e n t by personal behaviour that i s s e l f - s e r v i n g . Caring acknowledges the v u l n e r a b i l i t y of a c l i e n t i n c e r t a i n s i t u a t i o n s , and dictates r e s t r a i n t i n actions which might compromise the c l i e n t ' s r i g h t s and p r i v i l e g e s . Caring, involving a r e l a t i o n s h i p which i s , i n i t s e l f , therapeutic, demands mutual respect arid t r u s t . Caring acknowledges that'information obtained i n the course of the nursing r e l a t i o n s h i p i s p r i v i l e g e d , and that i t requires the f u l l p rotection of c o n f i d e n t i a l i t y unless such information provides evidence of serious im-pending harm to the c l i e n t or to a t h i r d party, or i s l e g a l l y required by the courts. Caring requires that the nurse represent the needs of the c l i e n t , and that the nurse take appropriate measures when the f u l f i l l m e n t of these needs i s jeopardized by the actions of other persons. Caring acknowledges the d i g n i t y of a l l persons i n the p r a c t i c e or educa-t i o n a l s e t t i n g . 99 13. Caring acknowledges, respects and draws upon the competencies of others. 14. Caring establishes the conditions f o r the harmonization of e f f o r t s of d i f f e r e n t helping professionals i n providing required services to c l i e n t s . 15. Caring seeks to e s t a b l i s h and maintain a climate of respect f o r the honest dialogue needed f o r e f f e c t i v e c o l l a b o r a t i o n . 16. Caring establishes the legitimacy of r e s p e c t f u l challenge and/or confron-t a t i o n when the service required by the c l i e n t i s compromised by incom-petency, incapacity or negligeance, or when the competencies of the nurse are not acknowledged or appropriately u t i l i z e d . 17. Caring demands the p r o v i s i o n of working conditions which enable nurses to carry out t h e i r legitimate r e s p o n s i b i l i t i e s . 18. Caring demands resourcefulness and r e s t r a i n t — a c c o u n t a b i l i t y f o r the use of time, resources, equipment, and funds, and requires a c c o u n t a b i l i t y to appropriate i n d i v i d u a l s and/or bodies. 19. Caring requires that the nurse bring to the work s i t u a t i o n i n education, p r a c t i c e , administration or research, the knowledge, a f f e c t i v e and techni-cal s k i l l s required, and that competency i n these areas be maintained and updated. 20. Caring commands f i d e l i t y to oneself, and guards the r i g h t and p r i v i l e g e of the nurse to act i n keeping with an informed moral conscience. Prepared f o r Canadian Nurses Association by M. Simone Roach, RN, PhD, csm and approved by Board of Directors February 1980 100 APPENDIX C DEPARTMENT OF MEDICAL NURSING PATIENT CARE STUDY - NURSE CONSENT FORM -j The nurses i n the Department of Medical Nursing are conducting a Patient Care Study. This present study i s aimed at the i d e n t i f i c a t i o n of r e l a t i o n -ships between patient a t t r i b u t e s , nurses' care giving preferences, and the qu a l i t y of patient care. The timing f o r t h i s study has been planned to coincide with the evaluation of the Nursing Process and i t s implementation i n October on 4 t r i a l wards. I expect that 45 minutes of your time w i l l be needed i n order for you to complete a patient r a t i n g questionnaire and a patient behaviour l i s t . I w i l l be present throughout the ratings and ava i l a b l e f or any questions i f they should a r i s e . This patient s e l e c t i o n technique has recently been tested with a sample of nurses on another nursing u n i t . I t was found to be highly r e l i a b l e . Since nurse, patient and ward anonymity as well as the c o n f i d e n t i a l i t y of information needs to be assured, i t i s of utmost importance that you do not , divulge the nature or content of our interview session to anyone u n t i l data c o l l e c t i o n i s completed (mid March, 1981). I f any questions or concerns a r i s e at any time regarding the study, please contact me. Your r e f u s a l to p a r t i c i p a t e or decision to withdraw from the study at a l a t e r time w i l l i n no way jeopardize your present or future p o s i t i o n i n nursing. I f you are w i l l i n g to p a r t i c i p a t e i n th i s study as described, please sign i n the space provided below. Thank you. Sincerely, NAME: DATE: Helen Garry, Registered Nurse, B.Sc.N. Nurse Researcher Department of Medical Nursing 101 DEPARTMENT OF MEDICAL NURSING  PATIENT CARE STUDY - PATIENT CONSENT FORM -The nurses i n the Department of Medical Nursing are conducting a study i n patient care. I am p a r t i c i p a t i n g i n th i s study for the nursing department i n order to measure the present q u a l i t y o f nursing care and to recommend im-provements i f indicated. The nurses on your ward have agreed to p a r t i c i p a t e i n th i s study and your doctor has received information so that he/she can o f f e r comments. 4 to 8 patients on most of the medical nursing wards i n the h o s p i t a l have been selected as p o t e n t i a l p a r t i c i p a n t s . I f you agree to p a r t i c i p a t e i n th i s nursing study I w i l l review your chart and ask you a few questions about your nursing care. C o n f i d e n t i a l i t y as well as anonymity of a l l the pa r t i c i p a n t s w i l l be assu r e d — o n l y code names w i l l be r e f e r r e d to i n the report of the find i n g s . I f any questions or concerns a r i s e at any time during or a f t e r the study, please contact your nurse or my o f f i c e . I f you should decide not to p a r t i c i p a t e i n this study or decide to with-draw from the study at any time, i t w i l l i n no way jeopardize your present or future nursing care. I f you are w i l l i n g to p a r t i c i p a t e i n th i s study as described, please sign i n the space provided below. Thank you. Sincerely, Helen Garry, Registered Nurse, B.Sc.N. Nurse Researcher Department of Medical Nursing NAME: DATE: 102 DEPARTMENT OF MEDICAL NURSING PATIENT CARE STUDY INFORMATION FOR PHYSICIANS The nurses i n the Department of Medical Nursing are conducting a Patient Care Study. This present study i s aimed at the i d e n t i f i c a t i o n of r e l a t i o n -ships between patient a t t r i b u t e s , nurses' care giving preferences and the q u a l i t y of nursing care. The timing f o r t h i s study has been planned to coin-cide with the evaluation of the Nursing Process and i t s implementation i n October on 4 t r i a l wards. Consents of agreement to p a r t i c i p a t e i n t h i s study have been received from the nurses on the ward and your patient, Mr/Mrs . The need for c o n f i d e n t i a l i t y of information and anonymity of a l l p a r t i c i -pants, including the ward and doctor, i s acknowledged and assured. The .design and protocol of t h i s study have been received and accepted by the U.B.C. Research on Human Subjects Committee, the Hospital's Nursing Research Committee and the C l i n i c a l Director of Medical Nursing. I f you have an'interest i n r e c e i v i n g a more de t a i l e d explanation or have questions or concerns regarding t h i s study, please contact me. Thank you. Sincerely, Helen Garry, Registered Nurse, B.Sc.N. Nurse Researcher Department of Medical Nursing 103 APPENDIX D PATIENT CLASSIFICATION FORM : l 2 ADMISSION TRANS.IN/LOA DISCHARGE TRAN.OUT/LOA 3 4 5 6 NUTRITION' NEEDS FEED PARTIAL ASSIST NUTRITION' NEEDS TOTAL ASSIST NUTRITION' NEEDS INTAKE § OUTPUT ROUTINE NUTRITION' NEEDS COMPLEX 7 8 9 10 ELIM NEEDS ELIMINATI ON ELIM NEEDS WOUND CARE ROUTINE ELIM NEEDS COMPLEX ELIM NEEDS SKIN CARE COMPLEX 11 12 CM O INHALATION THERAPY SIMPLE COMPLEX 13 14 15 16 17 ACTIVITY NEEDS PHYSICAL ACTIVITY PARTIAL ASSIST ACTIVITY NEEDS MAXIMUM ACTIVITY NEEDS PHYSICAL CARE PARTIAL ASSIST ACTIVITY NEEDS MAXIMUM ACTIVITY NEEDS SPECIAL REST NEEDS 18 19 •SJ CO HJ Q CO 2 PHYSICAL PROTECTION ASSESSMENT COMPLEX 20 21 22 SELF CONCP. SPECIAL EMOTIONAL SUPPORT SELF CONCP. LEARNING SIMPLE SELF CONCP. COMPLEX Scores 3 3 3 5 4 6 6 3 6 6 3 5 3 5 3 5 3 5 6 6 3 6 49. 104 APPENDIX E OBJECTIVE AND SUBOBJECTIVE STRUCTURE 1.0 The Plan of Nursing Care i s Formulated 1.1 The condition of the patient i s assessed on admission. 1.2 Data relevant to h o s p i t a l care are ascertained on admission. 1.3 The current condition of the patient i s assessed. 1.4 The written plan of nursing care i s formulated. 1.5 The plan of nursing care i s coordinated with the medical plan of care. 2.0 The Physical Needs of the Patient are Attended 2.1 The patient i s protected from accident and i n j u r y . 2.2 The need for phy s i c a l comfort and r e s t i s attended. 2.3 The need f o r physical hygiene i s attended. 2.4 The need f o r a supply of oxygen i s attended. 2.5 The need for a c t i v i t y i s attended. 2.6 The need f o r n u t r i t i o n and f l u i d balance i s attended. 2.7 The need f o r el i m i n a t i o n i s attended. 2.8 The need f o r skin care i s attended. 2.9 The patient i s protected from i n f e c t i o n . 3.0 The Non-Physical (Psychological, Emotional, Mental, Social) Needs of the Patient are Attended 3.1 The patient i s oriented to h o s p i t a l f a c i l i t i e s on admission. 3.2 The patient i s extended s o c i a l courtesy by the nursing s t a f f . 3.3 The patient's privacy and c i v i l r i g h t s are honored. 3.4 The need f o r psychological-emotional well-being i s attended. 3.5 The patient i s taught measures of health maintenance and i l l n e s s prevention. 3.6 The patient's family i s included i n the nursing care process. 4.0 Achievement of Nursing Care Objectives i s Evaluated 4.1 Records document the care provided for the pati e n t . 4.2 The patient's response to therapy i s evaluated. 5.0 Unit Procedures are Followed f o r the Protection of A l l Patients 5.1 I s o l a t i o n and decontamination procedures are followed. 5.2 The u n i t i s prepared f o r emergency s i t u a t i o n s . 105 6.0 The Delivery of Nursing Care i s F a c i l i t a t e d by Administrative and Managerial Services. 6.1 Nursing reporting follows prescribed standards. 6.2 Nursing management i s provided. 6.3 C l e r i c a l services are provided. 6.4 Environmental and support services are provided. APPENDIX F NURSING QUALITY MONITORING INSTRUMENT WORKSHEET 2001 SECTION A Information to be Obtained from Recorded Patient Information T H A T . 1.101 I F T H E P A T I E N T H A S P H Y S I C A L D I S A B I L I T I E S , E . G . S E N S O R Y O R M O T O R I M P A I R M E N T , S U C H N o A S I M P A I R E D H E A R I N G , V I S I O N , S P E E C H , E T C . , A R E T H E Y R E C O R D E D W I T H I N T H E F I R S T 24 Y e s 2 H O U R S O F A D M I S S I O N T O T H I S U N I T ? Not A p p l i c a b l e 3 C o d e N A if patient i n i t i a l l y admit ted to another u n i t . R e f e r s to type of d i s a b i l i t y , not to p r e s e n c e of pros the t i c d e v i c e . O b s e r v e r m u s t c h e c k p a -tient i f nothing r e c o r d e d . T o check with patient , ask patient: D O Y O U H A V E A N Y C I F F I C U L I T I E S T H A T I N T E R F E R E W I T H Y O U R G E T T I N G A R O U N D . S U C H A S D I F F I C U L T Y H E A R I N G , O R A R T H R I T I S , O R T H I N G S L I K E T . < If nothing r e c o r d e d and patient has p h y s i c a l p r o b l e m s o r d i s a b i l i t i e s , code as " n o . " If nothing r e c o r d e d and patient does not have p h y s i c a l d i s a b i l i t i e s , code as "not a p p l i c a b l e " 1.106 IS T H E R E A S T A T E M E N T W R I T T E N W I T H I N T H E F I R S T 24 H O U R S O F A D M I S S I O N T O T H I S U N I T N o 1 A B O U T T H E C O N D I T I O N O F T H E S K I N ? Y e s 2 Do not code N A A p p l i e s to a l l patients on this u n i t . R e f e r s to d r y n e s s , t u r g o r - h y d r a t i o n , absence o r p r e s e n c e o f s k i n l e s i o n s , l o c a l i z e d s k i n c o l o r w a r m t h , e t c . D o not accept g e n e r a l d e s c r i p t i o n s u c h as " P a l e " . -1 .206 A R E E I T H E R T H E D I E T O R T H E F O O D P R E F E R E N C E S O F T H E P A T I E N T R E C O R D E D W I T H I N T H E N o 1 F I R S T 24 H O U R S O F A D M I S S I O N TO T H I S U N I T ? ' Y e s 2 r-^> • * Not A p p l i c a b l e 3 oode N A if in format ion r e c o r d e d on a d m i s s i o n to another u n i t . C o d e N A if patient unable to g ive h i s t o r y on a d m i s s i o n . ' C o d e N A if char t unava i lab le on this unit 2001 , 01 1 .401 A . I n f o r m a t i o n to fcc O A R E G O A L S O F C A R E W R I T T E N ? S L C T I O N A '. u , ' ; 'om R e c o r d e d P a t i e n t I n f o r m a t i o n B . I F Y E S , A R E T H E G O A L S C U R R E N T ? "r"" T o n u r s e in charge of patient: IN Y O U R O P I N I O N , A R E T H E G O A L S O F C A R E W R I T T E N O N M R . ' S C A R E P L A N C U R R E N T ? 1.406 IS T H E D E S I R E D E X T E N T O F A M B U L A T I O N S T A T E D IN W R I T I N G , E . G . , IN T H E N U R S I N G C A R E P L A N , K A R D E X , E T C . , ? " Does not apply to patient up ad l ib o r patient on bed r e s t . R e f e r s to distance patient is expected to w a l k o r l e r g t h of t ime out of bed; inc ludes up to b a t h r o o m if patient walks to b a t h r o o m . 1 .410 IS T H E R E A P L A N F O R I N C R E A S I N G T H E P A T I E N T ' S I N D E P E N D E N C E O R R E S T O R I N G H I M T O A H I G H E R L E V E L O F F U N C T I O N IN A N O R G A N I Z E D M A N N E R , I . E . , G R A D U A L L Y I N C R E A S I N G S E L F -H E L P O R I N C R E A S I N G A C T I V I T Y ? A p p l i e s on ly if patient needs attention to s u c h c a r e . A p p l i e s lo c a r e not inc luded in m e d i c a l r e g i m e n . 2.115 IS T H E R E A L I S T O F P A T I E N T ' S A L L E R G I E S O N T H E F R O N T O F T H E C H A R T ? C h e c k r e c o r d to de termine If patient has a l l e r g i e s . 2.501 IS T H E P A T I E N T O U T O F B E D T H E N U M B E R O F T I M E S O R D E R E D ? C h e c k r e c o r d for previous day o n l y . M a y be N A only f o r patients up ad l i b , patients on b e d r e s t , o r infants and s m a l l c h i l d r e n . 2 . 6 0 4 IS T H E A M O U N T O F F L U I D I N T A K E A N D O U T P U T R E C O R D E D ? A p p l i e s if patient is on I&0, has s p e c i a l attention g i v e n to f lu id intake and output , o r is' i n the i m m e d i a t e pos t -operat ive p e r i o d . C o m p l e t e only if both intake and output r e c o r d e d and totaled f o r each shift in pas t 2 days . If patient has been on this unit l ess than two d a y s , a n s w e r on ly for t ime on this u n i t . 2001 ,02 No 1 Y e s 2 N o 1 Y e s , s o m e of the t ime2 Y e s , a l l o f the t i m e 3 No 1 Y e s 2 Not A p p l i c a b l e 3 N o 1 Y e s 2 Not A p p l i c a b l e 3 N o • 1 } Y e s 2 Not A p p l i c a b l e 3 No 1 Y e s 2 Not A p p l i c a b l e 3 N o 1 Y e s - I n c o m p l e t e 2 Y e s - C o m p l e t e 3 Not A p p l i c a b l e 4 SEC i iON A inic -mation to be Obtained from Recorded Patient Information A R E U N U S U A L H O W E L . O R U R I N A R Y P R O B L E M S N O T E D ( E . G . , P A S S I N G B L O O D , B U R K I N G , F R E -Q U E N C Y , I N C O N T I N E N C E , E T C . ) ? T o determine- ii' a pplicable, ask patient. "IN T H E P A S T T W O D A Y S , H A V E Y O U N O T I C E D A N Y -T H I N G D I F I - E R E N T W I T H Y O U R BOWP.'L.S O R C N U R I N A T I O N ? IS T H I S A P R O B L E M F O R Y O U ? " D o c s not rarer to routine d a i l y r e c o r d i n g (--.uch as graphic)Df bowel m o v e m e n t o r u r i n a r y ou t -put, unless r e c o r d s c l e a r l y state a p r o b l e m ex i s t s . . "Unusua l p r o b l e m s " are those defined as s u c h by the o b s e r v e r o r the pat ient . R e f e r s to all patients inc luding those with a u r i n a r y ca theter o r c o l o s t o m y . IS W R I T T E N C O N S E N T S E C U R E D P R I O R T O S P E C I A L P R O C E D U R E S A N D / O R S T U D I E S ? No Yes Not Applicable No Yes Includes any p r o r a d u r e for which wr i t ten consent mus t be g i v e n , e.g., s u r g e r y , l u m b a r punc- Not Applicable U i r e , etc . F o r last p r o c e d u r e on ly . F o r n u r s e r y o r p e d i a t r i c s - r e f e r s to w r i t t e n consent of parents . IS A D E S C R I P T I O N O F C A R E G I V E N B Y T H E F A M I L Y R E C O R D E D ? No Yes A s k patient to d e t e r m i n e if appl icable : D O Y O U R F A M I L Y A N D / O R F R I E N D S V I S I T Y O U IN T H E Not Applicable H O S P I T A L ? A R E T H E R E A N Y S P E C I F I C T H I N G S T H E Y D O F O R Y O U W H I L E T H E Y ARE H E R E 0 W H A T D O T H E Y D O ? I S " T H E P A T I E N T ' S P E R F O R M A N C E O F S E L F - C A R E A C T I V I T I E S ' E . G . . E A T I N G T O I L E T W A L K -I N G . D R E S S I N G , D O I N G O W N T R E A T M E N T S . E T C . ) R E C O R D E D ? A p p l i e s to hospi ta l s i tua t ion in past 48 h o u r s . No Yes Not Applicable 2001, C 8 SECTION B InformatiunUo be Obtained from Observation of the Patient and his Environmsr 2 . 1 0 6 A R E M E D I C A T I O N S F O R S E L F A D M I N I S T R A T I O N L A B E L E D W I T H P A T I E N T ' S N A M E A N D N A M E N o A N D D O S A G E O F D R U G S ? Y e s Not A p p l i c a b l e T o Patient: A R E T H E R E A N Y M E D I C I N E S Y O U A R E S U P P O S E D T O T A K E B Y Y O U R S E L F W H I L E IN T H E H O S P I T A L ? I F Y E S , C O U L D I P L E A S E S E E T H E M ? 2 . 1 0 7 IS T H E B E D S I D E T A B L E A N D O T H E R S E L F C A R E E Q U I P M E N T P O S I T I O N E D W I T H I N T H E P A T I E N T ' S N o R E A C H ? Y e s 2 .201 IS T H E P A T I E N T A B L E T O R E A C H T H E W A T E R G L A S S A N D P I T C H E R , U N L E S S C O N T R A I N D I C A T E T D N o B Y C O N D I T I O N O R T R E A T M E N T ? Y e s N o t A p p l i c a b l e Does not apply to infants and s m a l l c h i l d r e n . A l w a y s appl ies to adults unless N P O o r on r e -s t r i c t e d fluids o r r e s t r i c a t e d ac t i v i ty . If patient does not have both w a t e r g l a s s and p i t c h e r within r e a c h , code no. ? N o 2.301 A R E T H E P A T I E N T ' S N A I L S C L E A N ? ' y e s 2 . 3 0 5 IS T H E B E D P A N A N D / O R U R I N A L , I F R E Q U I R E D , C L E A N A N D S T O R E D IN B E D S I D E T A B L E O R B A T H R O O M ? IF P L A C E D C O N V E N I E N T L Y C L O S E T O P A T I E N T , IS E Q U I P M E N T C L E A N A N D C O V -E R E D ? Cede No if p laced on overbed table , on f l o o r , on window s i l l o r o t h e r a r e a except b e d . M u s t be c l ean and s t o r e d o r c o v e r e d f o r yes a n s w e r . 6 .405 IS T H E P A T I E N T S R O O M F R E E O F S M O K E ? NQt_.£Gn!iC<!L>!£ only if patient is in pr ivate r o o m and is s m o k i n g , o r if both patients in s e m i - p r i v a t e r o o m s m o k e . = N o t A p p l i c a b l e N o Y e s Not A p p l i c a b l e 2001, 04 S L L ' C ' i I O N C m o i - m a l i o n to b e O b t a i n e d f r o m I n t e r v i e w w i t h P a t i e n t 2 . 2 0 7 D O E S T H E P A T I E N T R E C E I V E P A I N M E D I C A T I O N P R O M P T L Y A F T E R R E Q U E S T I N G I T , O R A N E X - N o 1 P L A N A T I O N A S T O W H Y P A I N M E D I C A T I O N C A N N O T B E G I V E N P R O M P T L Y ? Y e s 2 Not A p p l i c a b l e 3 T o patient: IN T H E P A S T 2 D A Y S DID Y O U U S U A L L Y F . ' E C E I V E P A I N M E D I C A T I O N P R O M P T L Y A F T E R Y O U A S K E D F O R IT? IF a n s w e r is no . ask patient: DID T H E N U R S E E X P L A I N W H Y T H E M E D I C A T I O N W A S N O T G I V E N P R O M P T L Y ? T o patient 4 y e a r s and o lder : DID Y O U G E T P A I N M E D I C I N E O R A S H O T S O O N A F T E R Y O U A S K -E D F O R IT? If a n s w e r is no , ask patient: DID T H E N U R S E T E L L Y O U W H Y S H E C O U L D N ' T G I V E IT T O Y O U R I G H T A W A Y ? 2 . 2 1 0 IS T H E P A T I E N T O F F E R E D A B A C K R U B D A I L Y ? N o 1 Y e s 2 T o patient 7 y e a r s o r o lder : D O T H E N U R S E S A S K Y O U IF Y O U W A N T A B A C K R U B E A C H Not A p p l i c a b l e 3 D A Y ? A p p l i c a b l e f o r i m m o b i l e c h i l d r e n and a l l adu l t s . M a y be N A if patient's condi t ion c o n t r a i n d i -c a t c s - e . g . b u r n pat ient , B t c . T o a n s w e r yes mus t be o f f ered at least once in each 24 h o u r p e r i o d . 2 .212 IS T H L P A T I E N T ' S C A L L L I G H T A N S W E R E D I ^ O M P T L Y ? No 1 Y e s , s o m e of the t ime 2 T o pat i .ml o r parent: IN T H E P A S T "lAA/O D A Y S , W H E N Y O U / Y O U R C H I L D C A L L E D F O R A S S I S T - Y e s , m o s t of the t ime 3 A N C E , DID S O M E O N E G O M E T O T H E R O O M P R O M P T L Y ? Y e s , a l l of the t ime 4 Not A p p l i c a b l e T o c h i l d 4 yoars or older: F O R T H E P A S T C O U P L E O F D A Y S , W H E N Y O U C A L L E D A N U R S E , DID S O M E O N E C O M E T O Y O U R R O O M R I G H T A W A Y ? M a y be N A only if patient has not ca l l ed for n u r s e in past 2 d a y s . 200 ! , c .502 2 . 703 o. i, i ..-.tion to bo Obtained f r o m interview With Put lent VS T H E F ' A T I E N T A S S I S f t J WFI -I A D L ( E A T I N G , T O I L E T , D R E S S I N G , W A L K I N G , E T C . ) A S N E E D -E D ? ' T o patient or parent: !M T H E P A S T T W O D A Y S W H E N Y O U / Y O U R C H I L D N E E D E D S O M E H E L P IN D A I L Y A C T I V I T I E S , S U C H A S B A T H I N G , O R D O I N G T H I N G S F O R Y O U R S E L F , DID S O M E -O N E A S S I S " ! Y O U / H I M W I T H I N A R E A S O N A B L E A M O U N T O F T I M E ? T o c h i l d 4 years .••mil o lder : IN T H E P A S T C O U P L E O F D A Y S DID Y O U N E E D S O M E H E i _ P W I T H Y O U R B A T H OR D O I N G T H I N G S F O R Y O U R S E L F , DID S O M E O N E H E L P Y O U S O O N A F T E R Y O U A S K E D T H E M T O ? "Needed", "reasonable amount of t i m e " , and "soon af ter you a s k e d them" are def ined by p a -t ient . D O E S T H E N U R S I N G S T A F F A S S I S T T H E P A T I E N T T O T H E B A T H R O O M O R W I T H B E D P A N . ' U R I N A L W I T H I N A R E A S O N A B L E A M O U N T O F T I M E W H E N R E Q U E S T E D ? T o patient o r parent of ch i ld : IN T H E P A S T T W O D A Y S , H A V E Y O U / Y O U R C H I L D A S K E D FOR H E L P IN G O I N G T O T H E B A T H R O O M (OR W I T H T H E B E D P A N O R U R I N A L ) ? D I D THE NURSES G I V E Y O U / Y O U R C H I L D E N O U G H H E L P W I T H I N A R E A S O N A B L E A M O U N T OF TiME? N o 1 Y e s , s o m e of the t i m e 2 Y e s , m o s t of the t i m e 3 Y e s , a l l of the t ime 4 Not A p p l i c a b l e 5 No Yes Not Applicable 3.106 T o ch i ld 4 years and o lder : H A V E Y O U A S K E D F O R H E L P IN G O I N G T O T H E B A T H R O O M ( O R W I T H T H E B E D P A N / U R I N A L ) Y E S T E R D A Y A N D T O D A Y ? D I D T H E N U R S E S C O M E S O O N A F T E R Y O U A S K E D ? " A s s i s t a n c e needed", "reasonable amount of t i m e " , and "soon a f ter you a s k e d them" a r e def ined by the pat ient . IS T H E P A T I E N T T O L D H O W T O U S E T H E T E L E P H O N E O N A D M I S S I O N ? C o d e N A if patient in i t ia l ly admit ted to another uni t . No Yes Not Applicable . 107 T o patient 13 y e a r s and o l d e r ; W H E N Y O U W E R E F I R S T A D M I T T E D T O T H I S U N I T , DID S O M E -O N E T E L L Y O U H O W T O U S E T H E H O S P I T A L T E L E P H O N E ? If patient was not to ld wi th in 24 hours af ter a d m i s s i o n , code no . A c c e p t a b l e If v o l u n t e e r o r other n o n - n u r s i n g personne l i n f o r m e d patient . IS T H E P A T I E N T S H O W N N E C E S S A R Y F A C I L I T I E S , S U C H A S T H E L A V A T O R Y A N D B A T H R O O M , O N A D M I S S I O N ? C o d e N A i f p a t i e n t in i t i a l l y admitted to another unit o r if patient was not up to b a t h r o o m on a d m i s 5 i o n . N o Y e s Not A p d icable T o p s t U n l 4 y e a r s arid o lder : W H E N Y O U C A M E T O T H I S R O O M , DID S O M E O N E S H O W Y O U W H E R E [ H E B A T H R O O M OF-' P L A C E T O W A S H Y O U R H A N D S IS L O C A T E D ? If p a i i e n t w a : : n o t o h o w n w i t h i n the f i r s t TJ4 h o u r s of a c l i r i i . - : 3 i o n , ' c o d e no. 200-1, OS SEC", ION C I n f o r m a t i o n to b e O b t a i n e d r r o m I n t e r v i e w with P a t i e n t 3 . 2 0 l ' D O THE.' N U R S I N G S T A F F C A L L . P A T I E N T A N D F A M I L Y B Y D E S I R E D N A M E ? T o patient o r parent: W H E N S P E A K I N G T O Y O U A N D Y O U R F A M I L Y IN T H E P A S T T W C D A Y S , H A V E T H E N U R S I N G S T A F F C A L L E D Y O U B Y T H E N A M E Y O U P R E F E R ? T o c h i l d A years and old.vr: W H E N T A L K I N G T O Y O U A N D Y O U R F A M I L Y , D O T H E N U R S E S C A L L Y O U B Y T H E N A M E Y O U L I K E ? No 1 Y e s , s o m e of the t i m e 2 Y e s , mcs t of the t i m e 3 Y e s , a l l o f the t i m e 4 3 .402 D O T H b N U R S I N G S T A F F D I S C U S S T H E P H Y S I C A L D E P E N D E N C E - I N D E P E N D E N C E O F T H E P A T I E N T W I T H T H E P A T I E N T ? T o patient o r parent of ch i ld : H A S Y O U ' Y O U R C H I L D ' S I L L N E S S H A V E M U C H E F F E C T O N W H A T Y O U THE C A N D O F O R Y O U R S E L F ' H I M S E L F , S U C H A S D A I L Y H Y G I E N E O R E A T I N G . O R T A K I N G C A R E O F Y O U R S E L F / H I M S E L F IN G E N E R A L ? H , - S A N Y O N E F R O M T H E N U R S -I N G S T A F F T A L K E D IN D E T A I L W I T H Y O U / H I M A B O U T H O W M U C H Y O U / H E S H O U L D D O F O R Y O U R S E L F ' H I M S E L F O R H O W T O I N C R E A S E W H A T Y O U / H E C A N D O ? N o Y e s Not A p p l i c a b l e 1 2 3 T o c h i l d 3 years and o l d e r : S I N C E Y O U V E B E E N S I C K A R E T H E R E S O M E T H I N G S Y O U C A N ' T D O F O R Y O U R S E L F ? H A S T H E N U R S E T O L D Y O U W H A T Y O U C A N D O ? C o d e no if patient m e r e l y i n f o r m e d of ac t iv i t i e s but not engaged In discussion about the level of h i s / h e r involvement in c a r e . 3 . 4 0 6 D O T H E N U R S I N G S T A F F I N F O R M T H E P A T I E N T S A B O U T A C T I V I T I E S B E F O R E T H E Y A R E C A R R I E D O U T ? No Yes R e f e r s to routine r a r e a r t i v i t i e s : Does net r e f e r to obtaining consent f o r s p e r i a l p r o ' e d u r e s . Information m a y be m i n i m a l about what n u r s e is going to do . T o patient o r parent of ch i ld : D O T H E N U R S E S T E L L Y O U / Y O U R C H I L D W H A T T H E Y A R E G O I N G T O D O B E F O R E T H E Y C A R R Y O U T S O M E A C T I V I T Y S U C H A S B A T H S . I N J E C T I O N S . D R E S S I N G C H A N G E S , E T C . ? T o c h i l d 4 years S o lder : D O T H E N U R S E S T E L L Y O U W H A T T H E Y A R E G O I N G T O D O B E F O R E T H E Y D O T H I N G S , L I K E G I V I N G Y O U S H O T S . O R C H A N G I N G Y O U R D R E S S I N G S ? 3 . 4 1 0 D O N U R S E S L I S T E N T O T H E P A T I E N T ? T o patient o r parent of c h i l d : W H E N Y O U / Y O U R C H I L D T A L K T O T H E N U R S E O R A S K Q U E S T I O N S , D O Y O U F E E L T H A T S H E L I S T E N S T O Y O U / H I M A N D S H O W S A N I N T E R E S T IN W H A T Y O U / H E S A Y ? N o 1 Y e s , s o m e of the t lme2 Y e s , a l l o f the t ime 3 T o c h i l i . 4 years and o lder : W H E N Y O U T A L K T O T H E N U R S E , D O E S S H E L I S T E N T O Y O U A N D P A Y A i T E N T I O N T O W H A T Y O U S A Y ? 2001, 07 SECTION C Information to be Obtained from interview With Patient . 'Oo A R L THl:" P A T It NT OR F A M I L Y I N F O R M E D O F O R I N S T R U C T E D IN C A R E T H A T M U S T B E D O N E A T H O M E ? T o patient or p a r e i - , l : H A S A N Y O N E F R O M T H E N U R S I N G S T A F F T A L K E D T O Y O U Y E T A B O U T A N Y T H I N G Y O U ' Y C U R C H I L D C O U L D O R S H O U L D N O T D O W H E N Y O U G O H O M E ? N o 1 Yes, informed only 2 Yes, Informed & 3 instructed Not Applicable 4 3.602 P r o b e : s u c h cis ac t iv i ty l i m i t a t i o n s , c l i m b i n g s t a i r s o r other things? T o c h i l d A years and o lder: H A V E T H E N U R S E S T A L K E D T O Y O U A B O U T W H A T Y O U C A N D O W H E N Y O U G O H O M E ? P r o b e : L I K E H O W M U C H Y O U C A N P L A Y , Ol-? H O W M U C H Y O U C A N G O U P A N D D O W N T H E S T A I R S ? OR O T H E R T H I N G S ? A p p l i c a b l e as s o o n as it r a n be r e c o g n i z e d that patient w i l l need any k ind of in fo~mat ion about pos t -hosp i ta l a c t i v i t i e s . Does not r e q u i r e s p e c i f i c r e f e r r a l o r p h y s i r i a n s o r d e r s r e g a r d i n g d i s c h a r g e date o r a c t i v i t i e s . D O T H E N U R S E . P A T I E N T . A N D F A M I L Y D I S C U S S T H E F A M I L Y ' S P A R T I C I P A T I O N IN T H E C A R E O F T H E P A T I E N T ? T o patient A year-.; and older-: D O E S Y O U R F A M I L Y C O M E T O V I S I T Y O U ? IN T H E P A S T W E E K H A V E A N Y O F T H E N U R S E S T A L K E D W I T H Y O U A N D Y O U R F A M I L Y A B O U T W H A T T H I N G S T H E Y M I G H T H E L P Y O U D O ? No Yes Not Applicable R e f e r s to any ass i s tance p r o v i d e d by the f a m i l y . .406 IS T H E R O O M T E M P E R A T U R E C O M F O R T A B L E F O R T H E P A T I E N T ? No 1 Yes 2 T o patient: IS T H E T E M P E R A T U R E IN Y O U R R O O M C O M F O R T A B L E F O R Y O U N O W ? T o c h i l d 2 y e a r s o r o lder: IS T H E R O O M W A R M E N O U G H O R C O O L E N O U G H F O R Y O U ? 2001, 0a SECTION D Information to be Obtained from Interview with Nursing Personnel 3.603 IS O P P O R T U N I T Y P R O V I D E D F O R F A M I L Y T O D I S C U S S F E A I 5 S A N D A N X I E T I E S ' P A S T 2 D A Y S ) ? N o ' 1 Yes 2 T o nurse: H A V E M R . ' S F A M I L Y B E E N IN T C V I S I T H I M IN T H E P A S T 2 D A Y S ? N o t Applicable 3 If no, code N A . tn If y e s , ask nurse : HA V E A N Y O F T H E N U R S E S S P E N T S O M E T I M E W I T H T H E M T C S E E I F T H E Y H A V E A N Y P A R T I C U L A R F E A R S O R P R O B L E M S R E L A T E D T O M R . ' S I L L N E S S ? 2001, 09 116 APPENDIX G SELECTED S.P.S.S. PROGRAM OPTIONS FOR THE DISCRIMINANT FUNCTION ANALYSIS Stepwise Variable S e l e c t i o n Selection Rule: Maximize minimum : M^halanobis distance Maximum Number of Steps Minimum Tolerance Level Minimum F to Enter Maximum F to Remove Canonical . - Discriminant, Functions Maximum Number of Functions Maximum Cumulative Percent of Variance Maximum Sig n i f i c a n c e of Wilks' Lambda 72 . o . o i o 4.00 3.996 1 100.00 1.00 

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